MONETTE BOVELL
BRONX,NY
Summary
Results-driven quality control expert with expertise in ensuring compliance with industry standards and regulations. Strong analytical skills and a proven ability to resolve issues efficiently while promoting a collaborative team environment. Experienced in process improvement, risk assessment, and maintaining high-quality benchmarks. Additionally, skilled in hospital coordination, managing medical claim disputes, and overseeing third-level appeals. Seeking a coordinator or leadership role while pursuing a doctorate to contribute expertise and drive organizational success.
Overview
6
6
years of professional experience
Work History
Quality Control Reviewer III
1199 SEIU Benefit and Pension Fund
11.2022 - Current
- Review and verify submitted Pension applications and forms ensuring all required documentation is provided and complete
- Communicate with members, via telephone and/or email regarding claims and other benefit related inquiries; provide support to Telephone Representatives as needed
- Troubleshoot problems, take escalated calls retirees in resolving difficult and complex issues related to pension, claims, retiree benefits and payments, answer questions regarding policies, retiree programs and service
- Access web-based applications relevant to inquiries (i.e.: V3, QNXT, Super screen, BeneFaqs, Medco, iObserver, DocFind, etc.)
Telephone Representative II
1199 SEIU Benefit and Pension Fund
01.2020 - 11.2022
- Maintain HIPAA compliance while communicating with 1199SEIU members and advocates via telephone or written correspondence regarding benefit eligibility, claim submissions and plans, programs, and services
- Distinguish the benefit plans per Fund; identify their appropriate enrollment and eligibility rules and required documentation
- Verify, establish, and re-establish member eligibility for new or existing members, spouses and dependents using the eligibility and enrollment systems (Syntonic, QNXT, V3, and Member Portal)
- Request required proof of wages or hours worked as necessary; forward documentation to the Eligibility Department to update member eligibility records
- Research status of hospital and medical claim payments and benefit checks
- Verify coordination of benefits with other carriers and agencies
Grievance & Appeal Dispute Resolution Appeals Specialist
Emblem Health
08.2019 - 01.2020
- Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals. Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
- Resolve complex claim issues involving: 1st, 2nd, and 3rd level (IPRO) appeals; spreadsheet projects; reconsiderations; inquiries; adjustments; pending reports/DMS queues; medical records; e-mail communications; MedReview and Diagnostic Related Group determinations. Coordinate with Provider Relations, Eligibility, Authorization department, & Member Services, h where necessary
- Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
Office Coordinator II
Memorial Sloan Kettering Cancer Center
01.2019 - 07.2019
- Answer assigned phone lines promptly and professionally, directing calls appropriately and prioritizing effectively
- Organize and maintain shared communication software tools for the clinical teams, ensuring timely responses and clear communication
- Coordinate appointments, tests, consultations, treatments, and surgeries according to medical urgency, providing clear instructions to patients
- Prepare various documents including memos, correspondence, reports, and presentations, adhering to mandated formats and readability standards
- Manage authorizations and reimbursements for physician travel and meetings, maintaining licensure's and memberships for attending physicians
Education
Doctor of Public Health -
Capella University
12.2026
Skills
- Customer focus
- Auditing techniques
- Product inspection
- Quality management
Awards
- Resort World Gumbo Coalition Inaugural Class of 2021
- Honor Society 2023 Cumulative GPA: 3.8
Timeline
Quality Control Reviewer III
1199 SEIU Benefit and Pension Fund
11.2022 - Current
Telephone Representative II
1199 SEIU Benefit and Pension Fund
01.2020 - 11.2022
Grievance & Appeal Dispute Resolution Appeals Specialist
Emblem Health
08.2019 - 01.2020
Office Coordinator II
Memorial Sloan Kettering Cancer Center
01.2019 - 07.2019
Doctor of Public Health -
Capella University
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