Tamara Cline
Cincinnati,OH
Summary
Detail-oriented Grievance & Appeals Sr. Analyst with expertise in complex problem solving and cross-departmental communication. Proven ability to prepare case files and facilitate resolutions, ensuring compliance with regulatory requirements.
Overview
16
16
years of professional experience
Work History
Grievance & Appeals Sr. Analyst - Central Region
Elevance Health
Cincinnati, Ohio
09.2017 - Current
- Review, analyze and process complex grievances and appeals in accordance with external and internal accreditation and regulatory requirements, internal policies and pharmacy claims events requiring adaptation of written response in clear and understandable language.
- Prepare case files utilizing internal systems (Pega NextGen, PAHUB, CarelonRx CCA, Benefit Books) and route to nursing and/or medical staff for review.
- Complete and close appeal cases by sending clear and concise written communication to members and their providers once the determination has been made by the nursing/and or medical staff.
- Utilize guidelines and review tools to conduct research and analyze grievance and appeal issues, leading to informed resolutions of pharmacy prior authorization denials.
- Facilitate communication and resolution processes by liaising between grievance & appeal, medical management, legal, service operations, and other internal departments.
- Prepare case files and present them to IN and WI State Panel for review.
- Train and support new grievance and appeal analysts on standard and urgent pharmacy case processes, ensuring adequate coverage for weekend operations.
- Process urgent pharmacy appeal cases on weekends, as scheduled by management.
- Demonstrate ownership and accountability while meeting and/or exceeding individual production, timeliness and accuracy requirements every quarter.
Grievance & Appeal Intake Representative II
Anthem Medicare
Mason, Ohio
04.2013 - 09.2017
- Reviewed and assessed member and provider cases for urgency and validity, distributing to appeal analysts for timely processing.
- Prepared urgent and standard member & provider cases to be sent for clinical review within the timeframes established by Medicare.
- Addressed inquiries and appeals from member service, providers, vendors, and internal partners, facilitating effective communication and resolution.
- Maintained thorough documentation and logged case information on the MCAG tracking systems.
- Collaborated with team members to meet project objectives and deadlines, ensuring alignment on priorities.
Anthem Customer Service Representative I
Anthem Medicare
Mason, Ohio
09.2010 - 04.2013
- Delivered timely resolution of members' issues and complaints through excellent customer service.
- Resolved members' issues through effective communication and problem-solving skills.
- Provided detailed information about claims processing and appeals procedures.
- Maintained up-to-date knowledge of Medicare/Anthem regulations and guidelines.
- Maintained composure in stressful situations, effectively diffusing tensions to ensure positive member interactions.
- Recognized as Employee of the Month in October 2010 for achieving high production and timeliness standards.
- Transitioned from Central region member service only, to East region member and provider in April 2012.
- Partnered with team members to develop customer service strategies that improved member satisfaction.
Education
Business Accounting And Business Administration - Accounting And Finance
Instituto Comercial Reforma
Mexico City, Mexico05-1990
Skills
- Proficient in Pega NextGen, CarelonRx CCA, PAHUB, Knowledge Library, SharePoint, NPI Registry, ACMP, Filenet
- Excel knowledge and use
- Pharmacy claims analysis
- Complex problem solving
- Detail-oriented
- Time management
- Effective communication
- Team collaboration
- Case file preparation
- Grievance and appeal procedures
- Cross-departmental communication
- Medical documentation review
Timeline
Grievance & Appeals Sr. Analyst - Central Region
Elevance Health
09.2017 - Current
Grievance & Appeal Intake Representative II
Anthem Medicare
04.2013 - 09.2017
Anthem Customer Service Representative I
Anthem Medicare
09.2010 - 04.2013
Business Accounting And Business Administration - Accounting And Finance
Instituto Comercial Reforma