Nello Sorice
Revere,MA
Summary
To secure a position in a reputable organization to expand my knowledge and skills.
Overview
23
23
years of professional experience
Work History
Appeals and Grievances Representative
Boston Medical Center Health Net
04.2022 - 06.2022
- Executed member appeals across multiple departments within the Plan and with representatives from external vendors
- Initiated, drafted and issues appeal results determination letters to members and external vendors
- Communicated with members, providers and internal and external medical personnel to discuss appeal results when questions arise.
Grievances and Appeals Specialist
Papa, Remote
Miami, FL
12.2021 - 01.2022
- Responsible for the timely processing of grievances and complaints and all internal/external claim disputes.
Member Appeals Coordinator
AllWays Health Partners, Neighborhood Health Plan
Somerville, MA
05.2008 - 07.2021
- Served as contact and liaison for MassHealth, Department of Insurance (DOI) and the Office of Patient Protection (OPP)
- Thoroughly researched all appeals, gathered missing or required information, and prepared appeal cases for presentation to the Appeals Committee
- Processed member appeals while adhering to specifically defined appeal policies for MassHealth and
- Commercial members
- Assisted with Beacon Health Options appeals as requested by the AllWays Health Partners Manager of the Appeals and
- Grievances Department
- Assisted Management and Compliance Department in preparing appeal cases for upcoming audits by NCQA (National Committee for Quality Assurance), URAC (Utilization Review Accreditation Commission) and KEPRO (Keystone Peer Review Organization)
- Assisted in the notification to external agencies of appeal outcomes per MassHealth Board and OPP requirements
- Responsible for timely written notification to members on the acknowledgement and resolution of an appeal
- Stayed informed of changes related to AllWays Health Partners authorization and claims payment rules, benefit plans and new products
- Identified internal systematic or procedural issues and reported them to Management, the Director of Quality
- Control, Member Enrollment and any other appropriate department contacts for process improvement
- Worked with various external vendors including CVS caremark, MCMC and the Medical Review Institute of America (MRIoA)
- Reprocessed claims and investigated member eligibility issues
- Assisted Provider Appeals Coordinator with processing incoming provider appeals.
Senior Member Appeals Analyst
Tufts Health Plan Medicare Preferred
Watertown, MA
09.2003 - 05.2008
- Processed Member Appeals
- Led Member Appeals and Grievances staff
- Acted as a resource to fellow analysts
- Assisted department management as necessary
- Represented the department at interdepartmental meetings concerning company initiatives and projects
- Chaired and/or contributed to interdepartmental meetings as needed
- Identified time savers and process enhancements
- Developed workflows to put enhancements into place
- Identified and handled escalated and/or sensitive issues
- Supported department initiatives as needed
- Took on individual special assignments as needed
- Received and performed initial research on member appeals and categorized each appeal appropriately
- Corresponded with the member as required (Written acknowledgement, closure letters, telephone contact and documentation as appropriate)
- Completed data entry and documentation requirements in MACESS and in department databases
- Acted as a liaison and coordinated functions with internal departments relative to the status of a member appeal and the research needed to prepare the case for review
- Presented cases to the Member Appeals Committee on a bi-weekly basis
- Worked with Clinical Case Manager and Medical Director on all expedited issues
- Prepared cases for CMS external review
- Navigated the CMS website to determine Medicare benefit coverage criteria
- Familiar with Tufts Health Plan Medicare Preferred HMO and PPO plan rules
- Familiar with regulations and rules of The Part D Medication benefit
- Interacted with the Manager, Clinical Specialists, Grievance Analysts, Medical Directors, Case Management
- Department, Clinical Review Department, Department, Mental Health Department, Customer Relations
- Department, Claims Department, and many other departments regarding facilitating identification and resolution of grievance issues and appeal issues
- Responsible for the timely processing of expedited appeals received which require a seventy-two hour turnaround time
- Ensured all regulatory and department timelines were met.
Appeals and Grievances Analyst
Secure Horizons, Tufts Health Plan for Seniors
Watertown, MA
05.2001 - 09.2003
- Received and performed initial research on member appeals
- Categorized each appeal appropriately
- Corresponded with the member as required (Written acknowledgement, closure letters, telephone contact, and documentation as appropriate)
- Completed data entry and documentation requirements in MACESS and internal department databases
- Acted as a liaison and coordinated functions with internal departments relative to the status of a member appeal and the research needed to prepare the case for review
- Presented cases to the Member Appeals Committee on a bi-weekly basis
- Worked with Clinical Case Manager and Medical Director on all expedited issues
- Prepared cases for Centers for Medicare & Medicaid Services (CMS) external review
- Navigated the CMS website to determine Medicare benefit coverage criteria
- Familiar with Tufts Health Plan Medicare Preferred HMO and PPO plan rules
- Familiar with regulations and rules of The Part D Medication benefit
- Interacted with the Manager, Clinical Specialists, Grievance Analysts, Medical Directors, Case Management
- Department, Clinical Review Department, Legal Department, Mental Health Department, Customer Relations Department,
- Claims Department, and many other departments regarding facilitating identification and resolution of grievance issues and appeal issues
- Ensured all regulatory and department timelines were met.
GIC Member Specialist
Tufts Health Plan
Watertown, MA
06.1999 - 05.2001
- Provided superior customer service by meeting the General Insurance Commission (GIC) account guidelines (30 second call answer time, 0% not ready time)
- Adjusted and investigated member claims issues
- Investigated GIC enrollment issues.
Member/Provider Representative
Tufts Health Plan
Watertown, MA
11.1998 - 05.1999
- Provided superior customer service to Tufts Health Plan members
- Made necessary changes to member accounts (Address, phone number, date of birth and Primary Care Physician changes)
- Issued new identification cards when necessary
- Investigated enrollment issues.
Claims Specialist
First Notice Systems
Charlestown, MA
03.1998 - 10.1998
- Provided superior customer service to First Notice System clients
- Entered first notice of loss for various lines of business including workers compensation, commercial and personal liability, commercial and personal property, and commercial and personal auto insurance.
Education
Liberal Arts and Communications courses
Bunker Hill Community College
Skills
- MS Office: Excel, Outlook, Word, Adobe and SharePoint
Languages
Italian
Timeline
Appeals and Grievances Representative
Boston Medical Center Health Net
04.2022 - 06.2022
Grievances and Appeals Specialist
Papa, Remote
12.2021 - 01.2022
Member Appeals Coordinator
AllWays Health Partners, Neighborhood Health Plan
05.2008 - 07.2021
Senior Member Appeals Analyst
Tufts Health Plan Medicare Preferred
09.2003 - 05.2008
Appeals and Grievances Analyst
Secure Horizons, Tufts Health Plan for Seniors
05.2001 - 09.2003
GIC Member Specialist
Tufts Health Plan
06.1999 - 05.2001
Member/Provider Representative
Tufts Health Plan
11.1998 - 05.1999
Claims Specialist
First Notice Systems
03.1998 - 10.1998
Liberal Arts and Communications courses
Bunker Hill Community College