MONABEN T. PATEL
Tampa,Florida
Summary
Dedicated and detail-Oriented Appeals and Grievance Coordinator with over 11 years of experience managing complaints health care disputes Medicaid and Medicare.
Overview
1
1
Certification
12
12
years of professional experience
Work History
Grievance & Appeals Coordinator I
Centene- Sunshine Health
03.2023 - Current
- Gathered, analyzed, and reported verbal and written member complaints, grievances, and appeals to identify trends and inform resolution strategies.
- Review and process member and provider grievances and appeals within federal, state and organizational regulations and policies and procedures
- Prepare response letters for member and provider complaints, grievances, and appeals.
- Review claim grievance for reconsideration and either approve/deny based on determination level or prepare for medical review presentation. Prepared cases for medical review.
- Review and determine if claim auth grievance includes a potential quality or access issue.
- Coordinate the Grievance and Appeals Committee
- Assist with HEDIS production functions including data entry, auth and claim research.
Intake Representative II
Centene - Sunshine Health
02.2022 - 03.2023
- Executed member intake process using Prime, Trucare, Omni, NIA, and Turning Point, verifying eligibility and addressing authorization and claim denials.
- Processed transactions efficiently at point of sale.
- Ensure following established company guidelines.
- Classified incoming appeals and grievances to ensure accurate routing to appropriate departments.
Appeal Intake Representative-Medicare & Medicaid
WellCare -Centene
08.2014 - 02.2022
- Loaded appeals for provider and member cases using ICP, Pega, and Xcelys, expedited processing, and resolved escalated customer issues while working on special projects.
- Processed customer transactions efficiently at point of sale.
- Ensure store appearances are following established company guidelines.
- Classified incoming appeals, grievances, claim correspondence, and medical records to ensure accurate routing to appropriate departments.
- Operated databases to track, input, and provide information to management team and department.
- Experience onboarding new hires, mentoring mentoring program.
Education
Phlebotomy Technician -
Ultimate Medical Academy
Tampa, FlB.S. - Microbiology
Sarder Patel University
Vidhyanager, IndiaSkills
- Healthcare compliance knowledge
- Familiarity with medical necessity criteria, benefits Structures
- Data analysis
- Data interpretation
- Independent problem solving
- Well-organized and able to multi-task, prioritize, and manage time
- Effective communication skills
Certification
National CPT, Certification #D9K7FX8
OTHER RELEVANT COURSEWORK
- Genetics
- Lab Virology
- Biology I, II, and Lab
- Cell Biology
- Immunology
- Clinical Microbiology
Timeline
Grievance & Appeals Coordinator I
Centene- Sunshine Health
03.2023 - Current
Intake Representative II
Centene - Sunshine Health
02.2022 - 03.2023
Appeal Intake Representative-Medicare & Medicaid
WellCare -Centene
08.2014 - 02.2022
Phlebotomy Technician -
Ultimate Medical Academy
B.S. - Microbiology
Sarder Patel University