Sandra Lucatero
Bakersfield,USA
Summary
Qualified Risk and Compliance Analyst 1 with comprehensive background in managing appeals processes and ensuring compliance with regulatory standards. Successfully streamlined workflow procedures, resulting in improved efficiency and resolution times. Demonstrated analytical abilities and effective communication to liaise between stakeholders and resolve disputes.
Overview
6
6
years of professional experience
Work History
Grievance and Appeals Coordinator
Universal Healthcare MSO
Bakersfield
01.2025 - 03.2026
- The Appeals and Grievances (A&G) Coordinator is responsible for supporting the end-to-end A&G process, including the intake, tracking, and resolution of member and provider complaints and appeals. This position handles low complexity cases and performs administrative tasks such as organizing case documentation, monitoring deadlines, and ensuring timely follow-up. The A&G Coordinator collaborates with internal departments to resolve issues related to member eligibility, benefits, claims, utilization management, and pharmacy decisions. This role also involves training sessions and cross-functional work groups aimed at improving operational efficiency and service quality.
- Collaborated with cross-functional teams to enhance communication and efficiency in processes.
- Oversaw training programs for new hires on appeals protocols and systems usage.
- Ensured adherence to regulatory requirements while managing high-volume appeal cases effectively.
- Evaluated existing processes, recommending improvements to optimize performance and accuracy.
- Acted as a departmental resource on appeals matters.
Grievance and Appeals Coordinator
Kern Health Systems
Bakersfield
11.2019 - 12.2025
- Responsible for managing member complaints and appeals regarding coverage decisions, claim denials, and pre-service authorizations. Investigate cases by reviewing claim history, medical records, and supporting documents. Communicate with members, providers, and internal departments to gather information. Ensure grievances and appeals are processed within required timelines set by federal and state regulations such as Medicare, Medicaid, and health plan rules.
- Developed and implemented standard operating procedures to streamline workflow.
- Mentored junior staff on compliance regulations and best practices in appeals management.
- Analyzed complex case data to identify trends and improve appeal outcomes.
- Coordinated appeals process for efficient resolution of claims and disputes.
- Provided exceptional customer service by promptly responding to inquiries from appellants and other stakeholders.
- Participated in regular meetings with management to provide updates on case status and discuss potential improvements in processes.
- Monitored changes in regulations or policies, updating internal procedures accordingly to maintain compliance.
Education
High School Diploma -
Golden Valley High School
Bakersfield, CA04-2013
Associate of Science - Business Administration
Taft College
Taft, CA05-2029
Skills
- Telecommuting experience
- Knowledge of HIPAA regulations
- Organizational time management
- Claims submission efficiency
- Knowledge of Medicaid and Medicare programs
- Handling provider disputes
- Attention to detail
- Clear oral and written skills
- Customer engagement
- Effective phone handling techniques
- Multi-line phone management
- Skilled in maintaining a typing speed of 45 WPM
- Insurance eligibility verification
- Familiarity with Medi-Cal
- Understanding of health care administration principles
- Familiarity with health care compliance policies
- Understanding of legislative processes
- Research and analysis expertise
- Skilled in resolving conflicts effectively
- Experienced with Microsoft Word, Excel, and PowerPoint
- Documentation and reporting skills
- Independent issue resolution
- Reliable attendance record
Accomplishments
- Achieved an internal promotion to Grievance Coordinator at Kern Health Systems, recognized for exceptional oral and written communication skills and providing high-quality customer service. Successfully handled complex member issues by utilizing strong analytical and interpersonal abilities, ensuring regulatory compliance and resolution.
- Receiving recognition from Member Service Management at Kern Health System for exceptional customer service and written/oral communication skills is a significant, high-level achievement. This accolade highlights a commitment to excellent service standards, effective communication, and a positive contribution to both member relations and the organization's reputation
LANGUAGES
English
Spanish
Timeline
Grievance and Appeals Coordinator
Universal Healthcare MSO
01.2025 - 03.2026
Grievance and Appeals Coordinator
Kern Health Systems
11.2019 - 12.2025
High School Diploma -
Golden Valley High School
Associate of Science - Business Administration
Taft College