Summary
Overview
Work History
Education
Skills
Timeline
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Melissa J. Niska

Melissa J. Niska

Winston Salem,NC

Summary

Results-driven Complaints Analyst at CVS Health specializing in technical writing and detail-oriented analysis. Demonstrated success in resolving complex member complaints and streamlining communication processes. Strong critical thinking skills and ability to build effective interpersonal relationships lead to timely resolutions and improved member satisfaction.

Overview

27
27
years of professional experience

Work History

Complaints Analyst

CVS Pharmacy
Winston-Salem , NC
05.2019 - Current
  • Provide a detailed written explanation as it pertains to the member’s situation and concerns, while clearly communicating the coverage details of their benefits plan.
  • Responsible for the investigation and resolution of complaint scenarios for all products, which may contain multiple issues and may require coordination of responses from multiple business units.
  • Responsible for working with senior analysts and leaders to ensure quality in the written resolutions and letter correspondence sent to the beneficiary, including research information, grammar, and organization of letter.
  • Ensure timely, customer focused response to complaints. Research incoming complaints to identify if they are appropriate for the unit based on published business responsibilities.
  • Identify correct resource and reroute inappropriate work items that do not meet complaint criteria.
  • Research claim processing logic as it pertains to complaints, to verify the accuracy of claim payment, member eligibility data, and billing/payment status prior to the initiation of the appeal process.
  • Responsible for the coordination of all components of complaints, including final communication to the beneficiary for final resolution and closure.

Fraud Detection Representative

PSCU
08.2017 - 05.2019
  • Take incoming calls from credit union card holders to verify transaction activity on credit and debit cards
  • Place outbound calls in response to suspicious activity on card holder credit and debit cards
  • Analyze purchase patterns to detect possible fraud outside the routine scoring system
  • Analyze interactions with callers to detect possible fraudster callers attempting to compromise card holder information and gain access to accounts

Complaint and Appeals Representative

Health Net/Centene
07.2016 - 04.2017
  • Research and resolve all written member complaints within specified time frames
  • Process member appeals
  • Coordinate with other departments to address and resolve complaints
  • Triage incoming appeals and assign to coordinators

Complaints and Appeals Representative

VSP
04.1998 - 07.2016
  • Research and resolve all written member complaints within specified time frames.
  • Performed customer service and complaint resolution via email and live webchat.
  • Process member and doctor appeals; this includes case-by-case research, as well as paying overturned claims.
  • Detect and analyze trends in complaint documentation by phone agents.
  • Compile client-specific appeals information on a quarterly basis to provide to account managers.
  • Coordinate with other departments to address and resolve complaints.
  • Point of contact for complaint procedures specific to a select audience.
  • Compile California-specific complaint information quarterly to report compliance information to the DMHC.
  • Assist with client claim audits.
  • Create and maintain procedure pages for appeals processing.
  • Assist in maintaining team-specific procedures and documentation for reporting and daily workflow.
  • Assist in training new complaint and appeals representatives on all facets of the job.

Education

High School Diploma -

Yosemite High School
Oakhurst, CA
06-1990

Skills

  • Office software expertise
  • Microsoft SharePoint
  • Effective verbal and written communication
  • Technical writing and form development
  • Strong attention to detail
  • Fast and accurate typing
  • Critical thinking ability
  • Strong interpersonal skills

Timeline

Complaints Analyst

CVS Pharmacy
05.2019 - Current

Fraud Detection Representative

PSCU
08.2017 - 05.2019

Complaint and Appeals Representative

Health Net/Centene
07.2016 - 04.2017

Complaints and Appeals Representative

VSP
04.1998 - 07.2016

High School Diploma -

Yosemite High School

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Melissa J. Niska