Shaniece Cole
Indianapolis,Indiana
Summary
Experienced Grievance Coordinator with strong background in managing and resolving customer complaints. Exhibits strengths in communication, negotiation, and problem-solving skills, ensuring grievances are handled promptly and efficiently. Successfully enhanced overall customer satisfaction by implementing effective resolution strategies in previous roles. More than 8 years of successful experience in customer service and support with recognized strengths in claim modification and adjusting, trouble-shooting and solid computer skills. Excellent working knowledge using IBM systems; Typing speed of 80wpm
Overview
12
12
years of professional experience
Work History
Appeal and Grievance Coordinator
RepuCare
05.2024 - Current
- Developed and implemented grievance policies, procedures, and forms to ensure compliance with applicable labor laws.
- Monitored progress of grievance cases throughout the entire process to ensure timely completion.
- Prepared comprehensive reports summarizing results of investigations into member complaints and grievances.
- Reviewed documents for accuracy and completeness prior to processing appeals.
- Conducted research on evidence submitted in support of appeals.
- Developed strategies for efficient resolution of appeals cases.
- Provided guidance and assistance to other departments regarding the appeals process.
- Monitored complaint procedures to process and review complaints.
- Acted as an impartial mediator during negotiations between parties involved in a dispute.
- Reviewed existing policies and procedures related to member grievances for accuracy and effectiveness.
Appeals and Grievance Coordinator
Hays/Cognizant
08.2023 - 05.2024
- Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issues.
- Investigate and resolve insurance claim denials and disputes between a patient and provider.
- Serve as a liaison between grievances & appeals and/or medical management, legal, and/or service operations, and other internal departments.
- Identify opportunities for improvement, and provide support and assistance.
- Monitored progress made towards resolving appealed or grieved matters.
- Collaborated with other departments within the organization to identify potential solutions for resolving customer disputes.
- Analyzed complex cases to determine appropriate resolution in accordance with relevant laws, regulations and organizational policies.
- Assessed customer complaints to determine eligibility for appeal or grievance filing.
- Provided oversight of appeals and grievances process, ensuring compliance with applicable regulations.
- Prepared written responses to customers regarding the status of their appeal or grievance filings.
Appeal and Grievance Analyst
L.A Care Health Plan
11.2021 - 08.2023
- Conducted market research to identify trends and customer needs.
- Created reports, presentations, and other documentation
- Prepared written responses for customer inquiries regarding their appeals status.
- Utilized visualization tools such as Tableau or Power BI to present findings.
- Maintained positive working relationship with fellow staff and management.
- Coordinated with internal departments to ensure timely resolution of appeals.
- Analyzed medical records to determine if further information was needed in order to process appeals.
- Assisted customers with the appeals process, including providing guidance on how to submit an appeal.
- Maintained up-to-date knowledge of applicable laws, regulations, policies and procedures related to appeals processing.
Online Technical Support
Paychex
12.2019 - 11.2021
- Provided technical support to customers over the phone and via email.
- Resolved customer inquiries related to software applications, hardware issues, operating systems, and network connectivity.
- Diagnosed and troubleshot computer problems for customers by using remote access tools.
- Assisted customers with setting up new accounts on various software platforms.
- Tested system performance after installation or configuration changes were made.
- Created detailed reports of customer interactions for future reference and analysis.
- Maintained an organized database of all customer information including contact details and issue history.
- Developed and communicated Web site usage, security policies, and standards to users.
- Assisted customers with various types of technical issues via email, live chat, and telephone.
Provider Services Representative
Mindlance/Anthem
11.2018 - 12.2019
- Processed claims and coordinated with providers, payers, and other third parties as necessary.
- Resolved customer complaints and escalated more complex issues to senior staff members.
- Maintained detailed records of client communications in the company's database system.
- Developed relationships with new providers by providing guidance on how to use our systems, processes, and policies.
- Adhered to all applicable laws, regulations, standards, and procedures when interacting with customers and providers.
- Verified accuracy of submitted documentation prior to processing claims or services rendered.
- Participated in training sessions as needed to stay current on industry trends and best practices related to Provider Services Representative duties.
- Collaborated with team members to identify process improvement opportunities that could increase efficiency or reduce costs.
Assistant Manager
Kid Gloves
05.2017 - 11.2018
- Design and implement overall recruiting strategy
- Advised managers on best practices for interviewing techniques and selection criteria.
- Monitored recruitment trends and identified recruiting sources to meet hiring goals.
- Developed and maintained job postings, recruitment strategies, and applicant tracking systems.
- Managed the full cycle of recruitment process including sourcing, interviewing, screening and selection of candidates.
- Conducted background checks and reference checks on potential hires.
- Provided feedback to candidates throughout the hiring process.
- Organized orientation sessions for new employees to ensure smooth onboarding experience.
- Ensured compliance with all applicable federal and state laws and regulations governing employment practices.
- Attended career fairs, college events, industry conferences. to promote the organization's brand as an employer of choice.
Customer Service Representative
Anthem/AppleOne
08.2016 - 05.2017
- Greeted customers in a friendly and professional manner.
- Provided support to members regarding account inquiries, processing transactions, and resolving issues.
- Answered incoming calls regarding membership benefits and services.
- Handled customer complaints in an efficient and courteous manner.
- Maintained accurate records of member interactions and transactions.
- Adhered to all applicable policies, procedures, regulations, and laws.
- Responded promptly to emails from members seeking assistance.
- Researched complex issues related to accounts or services provided by the organization.
Customer Care Support
Mdwise Health Services
01.2016 - 08.2016
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Verified patient insurance coverage, including eligibility, benefits and authorizations for medical services.
- Provided guidance to providers regarding the prior authorization process.
- Coordinated with other departments to obtain additional information needed for prior authorization.
- Responded promptly to inquiries from providers, patients and payers regarding status of prior authorization requests.
- Maintained accurate records of all authorization activities in the database system.
- Researched clinical criteria and determined eligibility for requested services based on plan provisions.
Customer Service Representative
Renaissance Dental
02.2015 - 01.2016
- Resolved discrepancies between insurance companies and patients regarding payments, fees, and benefits.
- Verified accuracy of dental claims for completeness and compliance with insurance policies and regulations.
- Evaluated patient eligibility for services based on plan documents and state regulations.
- Reviewed insurance policy language to ensure accurate interpretation of benefit entitlements.
- Assisted with the development of procedures for processing dental claims in accordance with current standards.
- Responded to inquiries from providers regarding claim status, payment issues.
- Analyzed denied claims for potential resubmission or appeal opportunities.
Customer Service Representative
WellPoint
12.2013 - 02.2015
- Quickly and effectively solved customer challenges regarding insurance claims
- Maintained quality control/satisfaction records, constantly seeking new ways to improve customer service
- Developed strong relationships with customers by providing personalized assistance and support.
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Remained calm and professional in stressful circumstances and effectively diffused tense situations.
- Answered inbound calls, chats and emails to facilitate customer service.
- Asked probing questions to determine service needs and accurately input information into electronic systems.
- Informed customers about billing procedures, processed payments, and provided payment option setup assistance.
Customer Service Representative
Xerox
01.2013 - 12.2013
- Made arrangements with delinquent customers customer inquiries and provided accurate information regarding products and services.
- Gathered customer feedback through surveys and used the data to improve customer service.
- Assisted customers with product selection, ordering, billing, returns, exchanges and technical support.
- Maintained detailed records of customer interactions, transactions and comments for future reference.
- Performed administrative tasks such as filing paperwork, updating databases and generating reports.
- Developed strong relationships with customers by providing personalized assistance and support.
Education
High School Diploma -
Arlington High School
Indianapolis, IN01.2010
Skills
- Problem-solving abilities
- Professionalism
- Attention to Detail
- Investigation techniques
- Teamwork and Collaboration
- Recordkeeping skills
- Written Communication
- Multitasking
- Remote Office Availability
- Data Entry
Personal Information
Available: Available for interview with 24 – 48 hours of prior notice and can start immediately
References
References available upon request.
Timeline
Appeal and Grievance Coordinator
RepuCare
05.2024 - Current
Appeals and Grievance Coordinator
Hays/Cognizant
08.2023 - 05.2024
Appeal and Grievance Analyst
L.A Care Health Plan
11.2021 - 08.2023
Online Technical Support
Paychex
12.2019 - 11.2021
Provider Services Representative
Mindlance/Anthem
11.2018 - 12.2019
Assistant Manager
Kid Gloves
05.2017 - 11.2018
Customer Service Representative
Anthem/AppleOne
08.2016 - 05.2017
Customer Care Support
Mdwise Health Services
01.2016 - 08.2016
Customer Service Representative
Renaissance Dental
02.2015 - 01.2016
Customer Service Representative
WellPoint
12.2013 - 02.2015
Customer Service Representative
Xerox
01.2013 - 12.2013
High School Diploma -
Arlington High School
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