Olivia Mesina
Yakima,WA
Summary
Experienced Grievance Coordinator with strong background in managing and resolving customer complaints. Exhibits strengths in communication, negotiation, and problem-solving skills, ensuring grievances are handled promptly and efficiently. Successfully enhanced overall customer satisfaction by implementing effective resolution strategies in previous roles.
Overview
11
11
years of professional experience
Work History
Appeals & Grievance Coordinator II
AmeriHealth Caritas
Philadelphia, PA
05.2024 - Current
- Developed and implemented grievance policies, procedures, and forms to ensure compliance with applicable labor laws.
- Analyzed grievances received from employees to determine the scope of investigation and resolution.
- Conducted thorough investigations into employee grievances by interviewing witnesses, reviewing relevant documents, and gathering evidence.
- Provided guidance to management on appropriate responses to employee grievances in accordance with labor regulations.
- Collaborated with legal counsel to interpret labor laws and advise management on potential implications of proposed resolutions.
- Assisted in the development of strategies for resolving disputes between employees and management or other departments.
- Recommended corrective action plans based on findings from investigations into employee grievances.
- Monitored progress of grievance cases throughout the entire process to ensure timely completion.
- Prepared comprehensive reports summarizing results of investigations into employee complaints and grievances.
- Maintained accurate records related to grievance proceedings for future reference.
- Provided training sessions on conflict resolution techniques to managers and supervisors.
- Drafted letters notifying employees of decisions made regarding their grievances.
- Reviewed existing policies and procedures related to employee grievances for accuracy and effectiveness.
- Assisted in the implementation of new systems designed to streamline the grievance process.
- Monitored complaint procedures to process and review complaints.
- Trained employees on equal opportunity laws and provided avenues for reporting violations.
- Kept detailed records of interviews and data to meet compliance standards and support future reviews.
- Interviewed personnel involved in discrimination and equal rights complaints to collect information, outline grievances and mediate conflicts.
- Researched current trends in labor law regulations that may affect existing policies or procedures relating to employee grievances.
Appeals & Grievance
Centene Corporation
Indianapolis, IN
05.2019 - 12.2021
- Analyze and resolve verbal and written level 1 and IRO authorization appeals from providers and members while adhering to strict guidelines and time frames that following federal, state and internal regulations, policies, and procedures. - Process an average of 720 medical necessity and administrative appeals and 440 other cases annually - Research and reprocess claims affiliated with overturned authorizations - Provide correspondence and resolution letters for member and provider complaints and/or request. - Build and manage relationships with internal and external Customers, Clients and medical providers. - Coordinate appeal cases within multiple databases to ensure any issue, request, and/or questions are resolved with in a timely manner. (ex.Trucare, Prime, Omni, Amysis, AMR, Archer)
- Assist with production functions including data entry, calls to provider/Member, and claim research. - Practice leadership skills with obtaining monthly meetings amongst the team to coordinate quality workflows and maintain structure with the process. - Conduct training sessions for new procedures and system updates.
Appeals Coordinator/ Repricer
Equian
Indianapolis, IN
01.2014 - 03.2019
- Knowledge of Health insurance claims processing and experience with PPO background - Handling of Appeals and Disputes that provider/client requests. - Knowledge of networks such as PHCS, Multiplan, Asuris Regence, HMA, etc. - Reviews UB & HCFA claims forms for clean vs dirty claims. - Assists in re-pricing purchased and referred care approved UB & HCFA claims. - Assists in issuing purchase requisitions/invoices to services providers. - Handle and resolve customer and provider questions regarding the status of their claim. - Reprice daily assigned claims within required timeframe. - Data Entry of Health care claims on numerous operating systems external (Equip, Epic, Sharepoint) - Experience in problem solving, identifying trends, and reporting issues. - Microsoft Office experience (Excel, Outlook and Word) - Demonstrates ability to work independently with minimal guidance. - Establishes positive communications with all departments of Equian to assure stable operations. - Demonstrate respect and understanding of confidentiality for patients and clients according to policy and HIPPA regulation. - Assists in employee orientation and training new employee in network services department. - Participate in Equian staff meetings, assigned committees and community events, as instructed or deemed necessary
Education
High School Diploma -
Continental Academy
Miramar, FL01-2010
Skills
- Dispute Resolution
- Cross-functional coordination
- Policy Knowledge
- Cultural Competency
- Policy analysis
Timeline
Appeals & Grievance Coordinator II
AmeriHealth Caritas
05.2024 - Current
Appeals & Grievance
Centene Corporation
05.2019 - 12.2021
Appeals Coordinator/ Repricer
Equian
01.2014 - 03.2019
High School Diploma -
Continental Academy
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