Rachael Ross
Tampa
Summary
Versatile professional skilled in grievance and appeals coordination, with extensive experience in regulatory compliance and customer service. Contributions include developing training programs, streamlining communication, and enhancing team collaboration to optimize case management and uphold industry standards.
Overview
16
16
years of professional experience
Work History
Grievance & Appeals Coordinator I - Regulatory Team
CENTENE
Tampa
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.
- Created, composed and maintained appeal response templates.
- Acted as a departmental resource on appeals matters.
- Maintaining compliance with the regulatory laws and standards
- Ensures that the file is submitted to Maximus timely by CMS requirements
Customer Service Lead/Trainer/Platinum Escalations
United Healthcare
Tampa
10.2013 - 06.2021
- Assist newly hired employees with questions and navigate system.
- Handled 70-75 escalated calls per day and provided resolution to doctors and facilities regarding claims, prior authorization, billing, and appeal and grievance statuses.
- Introduced innovative strategies for streamlining workflow processes within the department, resulting in more efficient case resolution times.
- Streamlined communication channels within the department, promoting collaboration and teamwork among staff members.
- Use of complex computer systems for research regarding provider issues and documenting detailed notes regarding the interaction.
Trainer/Supervisor/Fraud Investigator
Mercantile Adjustment Bureau
Tampa
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.
- Mentored approximately 15-20 new hires per training class, resulting in stronger staff development and increased productivity.
- Provided one-on-one mentoring to help individuals reach their full potential within the organization.
Education
GED -
Leary Tech
Tampa, FLSkills
- High customer service standards
- HIPAA/PHI knowledge
- Commercial and Medicare / Managed Care insurance
- Training
- Conflict resolution proficiency
- Data entry proficiency
- Legal knowledge
- Policy Interpretation
- Organizational abilities
- Fraud Investigation
- Teamwork and Collaboration
- Appeals processing
- Claim analysis
- Regulatory compliance
- Documentation management
- Dispute resolution
- Performance monitoring
- Fraud detection
- Staff training
- Insurance regulations
- Medical terminology
- Appeals process proficiency
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
GED -
Leary Tech