Rene' Knight
Jeffersonville,IN
Summary
An Appeals & Grievance Coordinator with almost 2 years experience in a large Healthcare Insurance Company environment. Primarily focusing on Kentucky Health Plan member appeals and grievances with a goal of resolving a wide range of medical documented cases in a efficient and timely manner. Have been able to meet goals set by the company in both current and previous roles as a Grievance and Appeals coordinator and Customer Service Representative over the years in order to receive kudos from peers, supervisors and members which results in still receiving concurrent quarterly bonuses.
Overview
8
8
years of professional experience
Work History
Appeals & Grievance Coordinator
CVS Aetna
05.2022 - Current
- Responsible for research, analyzation and resolution of Kentucky Medicaid member/provider grievances and appeals to include a large variety of written correspondence to communicate outcomes.
- Responsible for ensuring complaint and appeal turnaround times are met and responses are HIPPA compliant with state and regulatory requirements when receiving resolutions back from different departments.
- Resolutions must be timely and include member focused solutions in both written and oral format.
- Required to meet weekly, monthly and yearly metric quotas in order to get quarterly bonuses and must stay compliant with company requirements to pass case audits done every month with the Supervisor of our department.
Telephone Collections Phone Agent
HCA Parallon (Position Will Be Ending Soon)
07.2019 - Current
- Responsible for placing outbound calls to consumers that have medical accounts from different medical facilities around the United States.
- Have to gain approval from a right party consumer to transfer the call to an customer service professional with the self–pay department for patient account servicing or leaving verbal messages with a person and/or answering machine to call the business back for further collection assistance.
Customer Service Representative
CVS Aetna
12.2015 - 05.2022
- Tenured customer service representative that handled a high volume of incoming phone calls in a remote call center.
- Received written requests or emails from our Kentucky Medicaid members, providers and internal staff regarding requests for ID cards, PCP/PDP changes, eligibility, benefits, COB/EOB questions including Medicare, claims and claim referrals, prior authorizations, nurse reviews, case management, provider relations involving credentialing and contracting issues and sent complaints and appeals to our Grievance and Appeals department for further review.
- Engaged, consulted, and educated members unique medical, pharmacy, dental or vision plan needs and preferences with the understanding of Aetna's rules, regulations and policies by using tools and resources to help guide the members along a clear path to care.
- Triaged call transfers to appropriate departments when applicable after requested information was given or was needed.
- Documented and tracked contacts with members, providers, plan sponsors and internal staff in the QNXT call tracking system.
Education
Associate of Applied Science - Paralegal
Oklahoma Junior College of Business And Technology
Oklahoma City, OK05.1992
High School Diploma -
Capitol Hill High School
Oklahoma City, OK05.1990
Skills
- Effective time management
- Written and verbal communication
- Proficient in Microsoft Office Suite/PC literate
- Proficient in medical terminology
- Knowledge of Medicaid and Medicare rules and regulations
- Customer service skills
- Understanding of prior-authorizations and claims/billing
- Multi-tasker
- Self-motivator
- Organizational skills
- Interpersonal skills
- Ability to meet deadlines and performance requirements
Timeline
Appeals & Grievance Coordinator
CVS Aetna
05.2022 - Current
Telephone Collections Phone Agent
HCA Parallon (Position Will Be Ending Soon)
07.2019 - Current
Customer Service Representative
CVS Aetna
12.2015 - 05.2022
Associate of Applied Science - Paralegal
Oklahoma Junior College of Business And Technology
High School Diploma -
Capitol Hill High School
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