Aneatra Harvey
Grievances And Appeals Analyst I
Rancho Cordova,CA
Summary
Detail-oriented Grievances and Appeals Analyst with extensive experience in managing dispute resolution processes within regulated healthcare environments. Expertise in interpreting contractual agreements, analyzing medical claims and records, and ensuring compliance with accreditation and regulatory standards. Recognized for exceptional written communication skills, ethical decision-making, and the ability to facilitate fair and timely resolutions to complex member concerns. Collaborative professional thriving in fast-paced settings while maintaining accuracy, confidentiality, and quality, consistently delivering efficient appeal resolutions and driving impactful policy enhancements.
Overview
18
18
years of professional experience
Work History
Grievances and Appeals Analyst
Elevance Health (Anthem)
Woodland Hills, CA
06.2023 - Current
- Review and process non-complex member grievances and appeals in accordance with regulatory requirements, accreditation standards, and internal policies.
- Conduct detailed research and analysis of grievance and appeal cases, including evaluation of claims data and medical records, to determine appropriate resolution or referral to clinical staff.
- Ensure all case reviews meet strict departmental guidelines and regulatory compliance requirements, including adherence to URAC and NCQA accreditation standards.
- Prepare clear and compliant written determination letters that effectively communicate case outcomes to members and stakeholders.
- Collaborate with medical management, legal teams, and internal operational departments to facilitate timely and accurate resolution of member concerns.
- Maintain confidentiality and compliance with healthcare regulations while managing sensitive member information and case documentation.
Program Technician II
State of California – Covered California
Sacramento, CA
12.2020 - 06.2023
- Responded to customer service contacts via the ACD system, providing information and guidance on health plan options.
- Conducted needs assessments for consumers, facilitating enrollment into plans via the HBEX (Health Benefit Exchange) and referred consumers to Medi-Cal Programs as needed.
- Delivered comprehensive information on health and dental insurance, including monthly premiums, to assist consumers in making informed decisions.
- Assisted consumers with enrollment inquiries and updated applications as necessary to ensure accuracy.
- Provided detailed benefit information to help consumers understand their coverage.
- Triaged cases to the next level of support when additional research or corrections were required for resolution.
- Assisted program applicants with form completion, document retrieval and resource management to reduce application delays.
- Developed customized programs tailored to meet specific client needs, resulting in increased customer satisfaction.
- Fostered positive relationships with external stakeholders such as vendors or consultants during collaborative projects.
Shield Concierge Claims Representative
Blue Shield of California
Rancho Cordova, CA
10.2017 - 11.2020
- Analyzed provider and commercial account contracts, ensuring compliance with relevant state and Federal laws.
- Facilitated meetings by providing agendas and researching statistical data from surveys to support informed decision-making.
- Resolved claim status inquiries, processed and adjusted claims as necessary, ensuring accuracy and adherence to protocols.
- Triaged cases to appropriate departments, meticulously documenting case statuses for streamlined resolution.
- Demonstrated proactive dispute resolution skills, resolving conflicts before escalation to Appeals and Grievances.
- Engaged members proactively, educating them on wellness plan options and promoting health literacy.
- Expanded proficiency in medical terminology, enhancing effectiveness in resolving member inquiries.
- Triaged complex cases to Registered Nurses when necessary, ensuring appropriate handling beyond standard authority.
- Addressed customer inquiries with timely and professional responses via phone, email and in-person interactions.
- Maximized guest satisfaction by promptly addressing concerns and resolving issues.
- Managed a variety of tasks simultaneously, maintaining professionalism and efficiency under pressure.
- Remedied issues quickly and effectively through active listening, conflict resolution, and dynamic communication skills.
- Greeted guests upon arrival and offered directions to key amenities to cultivate quality hotel experiences.
- Offered friendly and efficient service to customers, handled challenging situations with ease.
- Contributed to a positive work environment by maintaining a professional demeanor at all times.
- Assisted guests with special needs or requests, demonstrating empathy and understanding in every interaction.
- Provided exceptional customer service to diverse clientele, fostering an atmosphere of inclusivity and respect.
- Improved overall guest satisfaction by consistently exceeding expectations in all aspects of concierge services.
- Prioritized safety by remaining vigilant for potential security threats and reporting suspicious activity promptly when required.
- Ensured guest safety and security, monitoring public areas and managing access to guest floors.
- Facilitated smooth check-in and check-out processes, minimizing wait times and improving guest satisfaction.
- Improved customer satisfaction with prompt and accurate information about local attractions.
- Assisted in planning and executing special events, contributing to memorable guest experiences.
- Implemented feedback system for services provided, leading to continuous improvement in service delivery.
- Maintained accurate and up-to-date records of guest information.
- Responded to guest inquiries to maximize guest satisfaction.
- Maintained high level of professionalism and discretion when dealing with guests.
TA Client Service Representative
Franklin Templeton Investments
Rancho Cordova, California
11.2016 - 10.2017
- Responsibly managed routine inbound calls, adeptly addressing customer concerns and providing effective solutions to meet their needs.
- Handled complex financial inquiries related to funds, retirement plans, and market performance, ensuring accurate and comprehensive responses.
- Conducted intricate research for shareholders and financial advisors, delivering valuable insights and recommendations as required.
- Utilized multiple systems proficiently to gather and provide accurate market data to shareholders and financial advisors, enhancing decision-making processes.
- Processed high-value redemptions, purchases, and fund exchanges for shareholders and advisors, demonstrating meticulous attention to detail and adherence to procedures.
Senior Patient Account Representative
Dignity Health/Optum 360
Rancho Cordova, California
02.2015 - 11.2016
- Extensive expertise in healthcare insurance systems, encompassing HMO, POS, and PPO plans.
- Proficient in verifying insurance eligibility and securing necessary authorizations for medical procedures.
- Well-versed in medical coding, including ICD-9 and CPT coding systems.
- Exceptional problem-solving skills and resourcefulness in addressing patient concerns and resolving issues.
- Proactive in obtaining verifications and following up on pending authorizations to ensure timely processing.
- Skilled negotiator with a track record of advising on and recovering overdue or incorrect claims payments.
- Managed high-volume accounts, ensuring accurate and prompt payment of outstanding balances.
- Reduced aged accounts receivables by implementing effective follow-up strategies with patients and insurers.
- Established protocols for effectively managing escalated disputes related to billing issues or claim denials ensuring satisfactory resolution.
- Improved collections rate by proactively identifying trends within outstanding accounts and developing targeted solutions.
- Reconciled account discrepancies to maintain accurate records of payments received from both patients and insurance companies.
- Ensured compliance with all federal, state, and local regulations governing medical billing practices through continuous education on industry updates.
Customer Service Rep II
Health Net
Rancho Cordova, California
11.2007 - 02.2015
- Managed health plan data using automated systems, ensuring adherence to production and quality standards.
- Liaised with internal staff and external customers to verify information, facilitating efficient processing.
- Maintained strict confidentiality of medical records, adhering to privacy regulations.
- Handled 50-65 daily calls from healthcare providers and insurance customers, resolving inquiries promptly.
- Organized and maintained patient medical and financial records efficiently.
- Processed research requests and released information in compliance with regulations.
- Addressed insurance concerns and coordinated services to optimize patient care.
- Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Enhanced customer satisfaction by promptly addressing concerns and providing accurate information.
- Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
- Developed strong product knowledge to provide informed recommendations based on individual customer needs.
- Developed rapport with customers through active listening skills, leading to higher retention rates and positive feedback from clients.
- Exceeded performance metrics consistently, earning recognition as a top performer within the team.
Education
Bachelor of Arts - Sociology
California State University
Sacramento 05.2001 -
Skills
- Appeals & Grievances Resolution
- Medical Claims Review
- Analytical & Research Skills
Case evaluation
Problem-solving
Multitasking Abilities
Computer literacy
Self motivation
Adaptability and flexibility
Verbal and written communication
Workload prioritization
Policy analysis
Attention to detail
Analytical skills
Interpersonal skills
Written communication
Timeline
Grievances and Appeals Analyst
Elevance Health (Anthem)
06.2023 - Current
Program Technician II
State of California – Covered California
12.2020 - 06.2023
Shield Concierge Claims Representative
Blue Shield of California
10.2017 - 11.2020
TA Client Service Representative
Franklin Templeton Investments
11.2016 - 10.2017
Senior Patient Account Representative
Dignity Health/Optum 360
02.2015 - 11.2016
Customer Service Rep II
Health Net
11.2007 - 02.2015
Bachelor of Arts - Sociology
California State University
05.2001 -