Shenita Aviles
Douglasville,GA
Summary
Committed job seeker meeting company needs through consistent and organized practices. Skilled in working under pressure and adapting to new challenges, enhancing the organizational brand.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Member Services Representative I
Kaiser Permanente-Baltimore, MD
Baltimore, MD
02.2021 - 05.2022
- Receives and responds to inbound and outbound member inquiries calls for Kaiser Permanente
- Documented and escalated member complaints
- Assists Senior members with inquiries regarding Medicare
- Followed all Call center rules and regulations by Kaiser Permanente.
Intake Coordinator
Cigna Healthspring-Baltimore, MD
Baltimore, MD
11.2019 - 03.2020
- Received and responded to pharmacy for direct member reimbursements
- Used Onbase to view and process pharmacy appeals and claims.
Provider Service Representative
Maryland Physician's Care-Linthicum Heights, MD
Linthicum Heights, MD
09.2018 - 11.2019
- Receives and responds to all inbound provider general inquiry calls for Maryland Physician's care providers
- Assists providers with claim inquiries and Eligibility information
- Updates provider/member PCP changes in OMNI via faxed request from provider.
Member Service Representative
Randstad Staffing/ Kaiser Permanente
11.2017 - 02.2018
- Received and responded to inbound and outbound member inquiries calls for Kaiser Permanente
- Documented and escalated member complaints
- Followed all Call center rules and regulations by Kaiser Permanente.
Operations Admin
Blue Cross Blue Shield of NJ Horizon Medical Claims
03.2016 - 08.2017
- Performs reconciliation for all of Blue Cross Blue Shield of NJ Horizon Medical Claims (OCR, EDI, and Correspondence Enrollment, Member Reimbursement)
- Assists with Data Entry and entering claims into Facets for Horizon Blue Cross Blue Shield
- Enters and follows escalation tickets for any discrepancies
- Verified all claims were entered correctly in FACETS
- Participated in SSAE-Audits with members of management discussing quality improvement.
Clinical Administrative Coordinator
United Health Group-Baltimore, MD
Baltimore, MD
11.2010 - 01.2015
- Works closely with the Appeals intake nurses for QIO (Quality Improvement Organization) and Expedited appeals
- Verified and gathered any missing or invalid information for nurse level review (i.e
- Medical records, invalid claim submissions etc.)
- Creates all desk level procedures for Appeals Intake and Training materials
- Schedule meetings for any DLP updates and sent out daily reminder to employees via Microsoft Outlook - Appeals Intake Coordinator
- Received and reviewed appeals submitted by providers and forwarded completed appeal to the proper department
- Listened and graded all Member/Provider Service Representative calls and responses to ensure quality
- Scheduled meetings with representatives for calibration
- Received and responded to all member/provider inquires (i.e Member reimbursements, copayments, provider reimbursements, pharmacy inquires etc.) via fax, email, voicemail, and all phone related to Care Improvement Plus.
Grievance and Appeals Coordinator
Kaiser Permanente-Douglasville, GA
Douglasville, GA
Current
- Review and Investigation: Review appeals and grievances submitted by clients or customers
- Investigate the details and circumstances surrounding each case
- Documentation and Record-Keeping: Maintain accurate and detailed records of all appeals and grievances
- Document decisions and actions taken in response to each case
- Communication: Communicate with clients or customers to gather additional information if needed
- Provide updates and final decisions to clients or customers
- Policy Compliance: Ensure all appeals and grievances are handled in accordance with company policies and relevant regulations
- Stay updated on changes in laws and regulations that affect the appeals and grievances process
- Decision-Making: Analyze information and make informed decisions on the outcome of appeals and grievances
- Collaborate with other departments or teams to reach a resolution if necessary
- Reporting: Prepare regular reports on the status and outcomes of appeals and grievances
- Identify trends and provide insights to help improve processes and prevent future issues
- Customer Service: Provide high-quality customer service throughout the appeals and grievances process
- Handle escalated cases with professionalism and empathy
- Training and Development: Train staff on the appeals and grievances process and best practices
- Develop and update training materials as needed
- Process Improvement: Identify areas for improvement in the appeals and grievances process
- Implement changes to enhance efficiency and effectiveness.
Education
High School Diploma -
North County High School
Glen Burnie, MD06.2006
Some College (No Degree) - Nursing Administration
Bowie State University
Bowie, MDSkills
- Customer Service
- CSR
- Customer Care
- Call Center
- Customer Support
- DME
- Medical Billing
- Home Care
- EDI
- Calibration
- Medical Records
- Quality Assurance
- Medical Coding
- Oracle
- Business Analysis
- ERP Systems
- Process Improvement
- User Acceptance Testing
- ICD-10
- SAP
- Time management
- Microsoft Excel
- Data management
- Microsoft Access
- Medical terminology
- Accounts receivable
- CPT coding
- EMR systems
- Presentation skills
Certification
- Epic Certification
- Non-CDL Class C
- Medical Coding Certification
Timeline
Grievance and Appeals Coordinator
Kaiser Permanente-Douglasville, GA
Current
Member Services Representative I
Kaiser Permanente-Baltimore, MD
02.2021 - 05.2022
Intake Coordinator
Cigna Healthspring-Baltimore, MD
11.2019 - 03.2020
Provider Service Representative
Maryland Physician's Care-Linthicum Heights, MD
09.2018 - 11.2019
Member Service Representative
Randstad Staffing/ Kaiser Permanente
11.2017 - 02.2018
Operations Admin
Blue Cross Blue Shield of NJ Horizon Medical Claims
03.2016 - 08.2017
Clinical Administrative Coordinator
United Health Group-Baltimore, MD
11.2010 - 01.2015
High School Diploma -
North County High School
Some College (No Degree) - Nursing Administration
Bowie State University
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