Roberta Smith
Valencia,CA
Summary
Compassionate healthcare professional with extensive experience in case management, appeals, grievances coordination, and member advocacy for diverse populations. Proven ability to navigate complex systems while ensuring confidentiality and delivering high-quality outcomes. Currently transitioning into social work with aspirations to enroll in a Master of Social Work program, leveraging a strong background in client relations, crisis resolution, and culturally responsive service delivery. Actively seeking opportunities within community-based mental health or social service organizations to enhance practical experience, deepen knowledge of trauma-informed care, and support the well-being of vulnerable communities.
Overview
10
10
years of professional experience
Work History
Level II Grievance Coordinator
Alameda Alliance for Health
03.2024 - Current
- Conducted thorough investigations and research to effectively address intricate Medi-Cal grievances.
- Conducted in-depth research to pinpoint essential elements within EOC regulatory guidelines and DMHC/DHCS regulations to ensure compliance.
- Managed fluctuating monthly workload of 120 to 200 cases with consistent high-quality standards.
- Ensured compliance with state and federal regulations in all appeal and grievance processes.
- Executed detailed investigations to address and settle complex claim disputes efficiently.
- Collaborated with utilization management team to streamline care coordination efforts for Medi-Cal members.
Grievance Case Manager
Kaiser Permanente
06.2023 - 12.2023
- Supervised investigation procedures for complaints and grievances, guaranteeing thorough analysis and resolution of reported issues.
- Executed detailed evaluations of appointment histories, financial claims, provider documentation, and medication records using EMR systems such as Epic.
- Executed case processing for 75-90 cases each month to maintain operational efficiency.
- Developed and sent letters to facilitate resolution of issues related to member and provider complaints and appeals.
- Assessed and sanctioned refund and waiver requests concerning members' coinsurance and billing disputes, maintaining financial integrity for amounts up to $5000.
- Analyzed and optimized case resolution processes across departments, resulting in reduced turnaround time for complex grievances.
Training Assistant-Subject Matter Expert
Amazon
06.2022 - 09.2022
- Designed and delivered engaging training sessions to enhance employee onboarding experience over a four-week period.
- Analyzed and summarized weekly training progress for new hires, delivering insights to senior staff for informed decision-making.
- Oversaw evaluation processes to ensure all trainees met or exceeded minimum score of 80%.
- Developed and implemented training initiatives to enhance employee awareness of fraudulent behavior and prevention strategies.
- Provided guidance as a subject matter specialist to enhance team members' understanding of tasks and streamline process execution.
- Created targeted refresher modules aimed at resolving ongoing operational issues.
HR Assistant
Amazon
11.2020 - 09.2022
- Facilitated employee leave management by coordinating FMLA, short-term leave, and sick time requests efficiently.
- Delivered trauma-informed support to employees managing COVID-19 illness exposure and quarantine.
- Administered electronic employee records system, meticulously updating medical documentation to uphold data integrity and confidentiality.
- Facilitated timely processing and disbursement of sick pay leaves to meet required SLA deadlines.
- Provided comprehensive support to employees by addressing questions related to leave requests and compensation for leave of absence.
Appeals & Grievance Coordinator
United HealthGroup
01.2016 - 03.2019
- Investigated and processed patient appeals related to medication insurance approvals, enhancing patient access to necessary treatments.
- Delivered specialized support to teams, ensuring thorough review of medical appeals and grievances.
- Monitored and enhanced workflow efficiency for case processing, consistently adhering to 7-day turnaround expectations.
- Executed thorough evaluations of 40-60 appeals cases per week, contributing to efficient case management and decision-making processes.
- Coordinated with clinical nursing team to establish, execute, and assess comprehensive patient case management plans.
- Facilitated collaboration with billing department to ensure precise processing of co-pay and reimbursement payments.
- Applied CMS guidelines to accurately process case decisions and maintain regulatory standards.
- Drove timely resolution of escalated grievances by prioritizing urgent member issues, achieving substantial improvements in service responsiveness.
Education
Bachelor of Arts - Communications
California State University, Los Angeles
Los Angeles, CA06-2026
Skills
- Case management proficiency
- Patient Advocacy
- Care Coordination
- Resource Navigation & Referral Services
- Interdisciplinary Collaboration
- Clinical Documentation & Record Management
- Healthcare systems knowledge
- Cultural awareness
- Conflict Resolution
Timeline
Level II Grievance Coordinator
Alameda Alliance for Health
03.2024 - Current
Grievance Case Manager
Kaiser Permanente
06.2023 - 12.2023
Training Assistant-Subject Matter Expert
Amazon
06.2022 - 09.2022
HR Assistant
Amazon
11.2020 - 09.2022
Appeals & Grievance Coordinator
United HealthGroup
01.2016 - 03.2019
Bachelor of Arts - Communications
California State University, Los Angeles