Summary
Overview
Work History
Education
Skills
Educationandskills
References
Timeline
Generic

RENE COUSIN-JONES

Richmond,VA

Summary

Insightful Appeals Analyst known for high productivity and efficient task completion. Possess specialized skills in regulatory compliance, case management systems, and legal research. Utilize critical thinking, communication, and problem-solving abilities to excel in challenging situations. Committed to delivering precise analysis and fostering positive outcomes in all endeavors.

Skilled in navigating complex insurance claims and providing thorough investigations to ensure fair settlements. Have experience coordinating with legal teams, policyholders, and insurance companies to manage claims efficiently. Known for strong analytical skills, ability to interpret policy details accurately, and effective communication that results in resolved disputes. Made significant impacts by streamlining claims processing procedures, enhancing customer satisfaction through timely resolutions.

Overview

20
20
years of professional experience

Work History

Appeals Analyst

Aetna
Richmond, VA
08.2021 - Current
  • Review, investigation and resolution of appeals, complaints, and grievance scenarios for all products, which may contain multiple issues and may require coordination of responses from multiple business units
  • Ensure timely, customer focused response to appeals, complaints, and grievance
  • Identify trends and emerging issues and report and recommend solutions
  • Reviewed and research incoming electronic appeals, complaints, and grievance to identify if appropriate for unit based upon published business responsibilities
  • Identify correct resource and reroute inappropriate work items that do not meet appeals, complaints, and grievance criteria
  • Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial
  • Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process
  • Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services
  • Triage incomplete components of appeals, complaints, and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response
  • Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure
  • Serve as a reviewer and technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise
  • Identifies trends and emerging issues and reports on and gives input on potential solutions

Grievance and Appeals Analyst II

Anthem
Richmond, VA
04.2018 - 09.2021
  • Reviewed, analyzed, and processed non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language
  • Utilized guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review
  • The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements
  • Followed department guidelines and tools to conduct their reviews, and completion of the respective written communication documents to convey the determination
  • Reviewed components of the URAC and NCQA accreditations are 'must pass' items to achieve the accreditation
  • Served as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments
  • Obtained cooperation from these other areas requires an awareness of their functions and necessitates the development and maintenance of relationships to include instilling an awareness of our customer expectations and responses
  • Conducted any utilization or medical management review activities which require the interpretation of clinical information
  • Identified opportunities for improvement and any provide support and assistance to G & A Analyst I associates as needed

Medical Management Specialist II

Kelly Services/Anthem
Richmond, VA
10.2014 - 04.2018
  • Provided non-clinical support to medical management operations, which includes handling more complex file reviews and inquiries from members and providers
  • Gathered clinical information regarding case and determines appropriate area to refer or assign case utilization management, case management, QI, Med Review)
  • Conducted initial review of files to determine appropriate action required
  • Maintained and updated tracking databases
  • Prepared reports and documented all actions
  • Responded to requests, calls, or correspondence within scope
  • Provided general program information to members and providers as requested
  • Reviewed and assisted with cases
  • Acted as liaison between medical management operations and other internal departments to support ease of administration of medical benefits
  • Assisted with case referral process
  • Collaborated with external community-based organizations to facilitate and coordinated care under the direction of an RN Case Manager
  • Tracked referral according to specified timelines and notifies providers and families of CCS eligibility determinations and referrals, BCC authorizations and/or deferrals
  • Conducted any utilization management review activities which require interpretation of clinical information

Certified Nursing Assistant

Henrico Health & Rehabilitation Center
Richmond, VA
12.2013 - 12.2014
  • Provided direct care to the residents of the health and rehabilitation center
  • Assisted them in activities of daily living under the direction and supervision of a professional nurse
  • Assisted patients with bathing, dressing, serves and collects food trays, feeds residents, measures and records weight, temperature, blood pressure, pulse and respiration rates, and food and fluid intake and output as directed
  • Communicate with family members with the progression and at times the regression of their loved ones

Customer Service Representative

LogistiCare Solutions
Richmond, VA
08.2012 - 07.2013
  • Provided knowledgeable responses to telephone inquiries in a courteous and professional manner
  • Ensured all company procedures are followed
  • Ensured accurate trip data is input in our systems
  • Assisted customers with transportation questions and concern, including scheduling, modifying, and canceling customer reservations
  • Spoked with members daily and answer their transportation questions, all while helping support them in their journey towards positive health outcomes
  • Obtained and documented details of complaints being filed and referred unresolved customer grievances to designated department for further investigation and resolution
  • Resolved escaladed calls within Medicaid guidelines and meeting the customer
  • Reviewed and educated members on our services and their insurance coverage

Compliance Specialist

Apex Systems Inc.
Richmond, VA
04.2012 - 08.2012
  • Researched and conducted procedures audits based upon client regulatory and internal requirements
  • Provided analysis of records, reports, regulations and operating procedures and practices
  • Assisted with research related to process improvement activities and administered a wide variety of personnel policies and programs
  • Communicated with other employees, departments, administrators, applicants, and the public for the purpose of providing information and assistance concerning employment, substitute procedures, personnel records, and related legal requirements
  • Developed a wide variety of written materials (e.g., forms, procedures, brochures, pamphlets, etc.) for the purpose of documenting activities, providing written reference, and/or conveying information
  • Processed documents, data, and materials (e.g
  • Human Resources Information System, etc.) for the purpose of disseminating information to appropriate parties and inputting data
  • Researched information required to manage assignments including reviewing relevant policies and current practices for the purpose of ensuring compliance with legislative requirements, securing general information for planning and/or responding to requests from various state and federal agencies

Customer Service Representative

LogistiCare Solutions
Richmond, VA
09.2010 - 04.2012
  • Ensured all company procedures are followed
  • Ensured accurate trip data is input in our systems
  • Assisted customers with transportation questions and concern, including scheduling, modifying, and canceling customer reservations
  • Spoked with members daily and answer their transportation questions, all while helping support them in their journey towards positive health outcomes
  • Obtained and documented details of complaints being filed and referred unresolved customer grievances to designated department for further investigation and resolution
  • Resolved escaladed calls within Medicaid guidelines and meeting the customer
  • Reviewed and educated members on our services and their insurance coverage

Customer Service Representative

Vangent
Chester, VA
05.2007 - 06.2010
  • Provided knowledgeable responses to telephone inquiries in a courteous and professional manner
  • Answered general Medicare eligibility, coverage, enrollment, and general information on Medicare, including Choice, Medigap, and Medicare Part D Drug Coverage
  • Conducted referrals to other agencies such as Social Security or Medicaid
  • Adhered to the Privacy Act as it relates to the confidentiality of information released
  • Answered media topics such as flu shots, surveys, drug coverage, etc
  • Maintained appropriate documentation of phone inquiries
  • Administer daily and weekly reports and assist supervisors with developing customer service representatives through feedback and coaching
  • Facilitated calibration sessions and gave feedback to those supervisors who are unable to attend

Administrative Assistant

Boehringer Ingelheim
Chesterfield, VA
01.2007 - 03.2007
  • Maintained and constructed employees training records
  • Improved the records management and forms control for the organization’s personnel
  • Maintained filing system that housed confidential, classified documents, and administrative actions
  • Managed the reception/switchboard, organizing meetings & typing/ filing of minutes & maintenance of office correspondences
  • Supported sales tasks by preparing weekly & monthly sales reports, tracking and reporting sales activities, facilitating & reconciling field force promotion & travel expenses plus coordination of the logistics for company events
  • Ordered & kept inventory of office supplies, maintained equipment in acceptable working & clean conditions, settled utility bills too
  • Calendar support for leadership, coordination of conference rooms and meetings, ordering and managing departmental supplies, travel arrangements and expense report reconciliation, and general support
  • Performed all Company business in accordance with all regulations and Company policy and procedures

Customer Service Representative

Pearson Government Solutions
Chester, VA
06.2005 - 03.2006
  • Provided knowledgeable responses to telephone inquiries in a courteous and professional manner
  • Answered general Medicare eligibility, coverage, enrollment, and general information on Medicare, including Choice, Medigap, and Medicare Part D Drug Coverage
  • Conducted referrals to other agencies such as Social Security or Medicaid
  • Adhered to the Privacy Act as it relates to the confidentiality of information released
  • Answered media topics such as flu shots, surveys, drug coverage, etc
  • Maintained appropriate documentation of phone inquiries
  • Administer daily and weekly reports and assist supervisors with developing customer service representatives through feedback and coaching
  • Facilitated calibration sessions and gave feedback to those supervisors who are unable to attend

Education

Certified Nursing Assistant -

Asher Comprehensive Training Center

Skills

  • Microsoft Office
  • 10 keys by touch
  • Typing speed of 40 wpm
  • Excel
  • Spreadsheet
  • Team building
  • Reliability
  • Adaptability and flexibility
  • Multitasking capacity
  • Analytical skills
  • Staff management
  • Medical records review
  • Information gathering

Educationandskills

Asher Comprehensive Training Center, Certified Nursing Assistant, Business Application with Microsoft Office, 10 keys by touch, Typing speed of 40 wpm

References

References available upon request.

Timeline

Appeals Analyst

Aetna
08.2021 - Current

Grievance and Appeals Analyst II

Anthem
04.2018 - 09.2021

Medical Management Specialist II

Kelly Services/Anthem
10.2014 - 04.2018

Certified Nursing Assistant

Henrico Health & Rehabilitation Center
12.2013 - 12.2014

Customer Service Representative

LogistiCare Solutions
08.2012 - 07.2013

Compliance Specialist

Apex Systems Inc.
04.2012 - 08.2012

Customer Service Representative

LogistiCare Solutions
09.2010 - 04.2012

Customer Service Representative

Vangent
05.2007 - 06.2010

Administrative Assistant

Boehringer Ingelheim
01.2007 - 03.2007

Customer Service Representative

Pearson Government Solutions
06.2005 - 03.2006

Certified Nursing Assistant -

Asher Comprehensive Training Center

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RENE COUSIN-JONES