Summary
Overview
Work History
Education
Skills
Timeline
Generic

RACHAEL ROSS

Tampa,FL

Summary

Health Insurance Representative versed in customer support in high call volume environments. Superior computer skills and telephone etiquette. Eager to utilize over 20 years of customer service, training, supervisor and office experience to secure a position. Highly organized, efficient and skilled in a variety of healthcare insurance roles including but not limited to trainer, team lead, appeals and escalation specialist. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.

Overview

25
25
years of professional experience

Work History

Grievance & Appeals Coordinator I - Regulatory Team

CENTENE
06.2021 - Current
  • Prepare Medicare denied appeal files for submission to Maximus Federal Services by analyzing the appeals regarding non-participating claims, member medical and dental claims, and authorization denials for medical and dental
  • Review of the files to determine that the decision for appeal is correct
  • Ensuring that all information and all documents are within the file that are required
  • Creating the Reconsideration Background Data Form outlining the details of the appeal along with the Medicare Health Plan Rationale for the appeal denied decision
  • Preparing the documents in proper order
  • Maintaining compliance with the regulatory laws and standards
  • Ensures that the file is submitted to Maximus timely by CMS requirements
  • Assist with other projects when needed.

Customer Service Lead/Trainer/Platinum Escalations

United Healthcare
10.2013 - 06.2021
  • Assist newly hired employees with questions and navigate system.
  • Assist in training with side by sides of new hires
  • Handled escalated calls and provided resolution to doctors and facilities regarding claims, prior authorization, billing, and appeal and grievance statuses
  • Coached a team of customer service representatives to meet production and call center measures
  • Use of complex computer systems for research regarding provider issues and documenting detailed notes regarding the interaction
  • Assist with high call volume from providers when the queue is high and overflow when needed.

Trainer/Supervisor/Fraud Investigator

Mercantile Adjustment Bureau
01.2010 - 10.2012
  • Responsible for fraud mitigation for retail clients
  • Development of the call center operations, quality and training processes
  • Handled supervisor duties such as escalated calls, scheduling of breaks and monitoring customer care reps call quality and work performance.

Trainer/Customer Service Lead

DHL HOLDINGS
01.2000 - 08.2007
  • Responsible for training new hires for high volume inbound call center regarding package tracking, shipping and delivery
  • Develop training courses for new hires as well as continuous on job training.

Education

Leary Tech
08.2013

Leto Highschool
06.1996

Skills

  • High customer service standards
  • Strong problem-solving skills
  • HIPAA/PHI knowledge
  • Commercial and Medicare / Managed Care insurance
  • Training
  • Medical Terminology
  • Highly organized and efficient
  • Conflict resolution proficiency
  • Strong oral, written and problem-solving skills
  • Data entry proficiency
  • Legal knowledge
  • Policy Interpretation
  • Organizational abilities
  • Teamwork and Collaboration

Timeline

Grievance & Appeals Coordinator I - Regulatory Team

CENTENE
06.2021 - Current

Customer Service Lead/Trainer/Platinum Escalations

United Healthcare
10.2013 - 06.2021

Trainer/Supervisor/Fraud Investigator

Mercantile Adjustment Bureau
01.2010 - 10.2012

Trainer/Customer Service Lead

DHL HOLDINGS
01.2000 - 08.2007

Leary Tech

Leto Highschool
RACHAEL ROSS