Summary
Overview
Work History
Education
Skills
Affiliations
Accomplishments
References
Timeline
Generic

Nichole Rosales

Oxnard

Summary

Results-driven Grievance and Appeals Analyst Lead skilled in regulatory compliance, process improvement, and conflict resolution. Proven ability to mentor teams and optimize workflows for enhanced operational efficiency.

Overview

25
25
years of professional experience

Work History

Grievance and Appeals Analyst Lead

Anthem Inc.
Woodland Hills
06.2022 - Current
  • Provided analytical support to associates and management on workflows and policies.
  • Collaborated with internal teams to resolve complex case issues efficiently.
  • Monitored, trended, and analyzed grievance and appeals data for accurate submission.
  • Served as clinical resource expert and mentor for complex regulatory issues.
  • Reviewed internal audits of grievance and appeals processes for compliance.
  • Ensured resolution of appeals and grievances within regulatory timeframes.
  • Trained, coached, and evaluated performance of analyst associates.
  • Implemented process improvements for handling appeals more effectively.
  • Educated staff on appeal processes and best practices for case management.
  • Prepared detailed reports summarizing appeal results.

Grievance and Appeals Analyst

Anthem Inc.
Woodland Hills
01.2021 - 06.2022
  • Reviewed and analyzed complex grievances and appeals submitted by members and authorized representatives.
  • Conducted extensive research using guidelines and review tools for accurate coverage determinations.
  • Ensured compliance with regulatory standards and requirements throughout processes.
  • Researched relevant laws and guidelines to support appeal decisions.
  • Collaborated with legal counsel as needed during the course of an appeal.
  • Attached necessary documentation and supporting evidence to each case.
  • Communicated coverage determinations clearly through professionally written correspondence to relevant parties.
  • Provided assistance to teammates regarding inquiries via Microsoft Teams group chat.
  • Demonstrated strong verbal and written communication skills in all interactions.
  • Specialized in claims, benefits, pharmacy, clinical matters, and enrollment and billing.

Operations Expert

Anthem, Inc.
Newbury Park
01.2020 - 01.2021
  • Supported frontline associates and management in workflow, policies, and technical issues.
  • Led a team of over 26 permanent staff representatives to achieve operational goals.
  • Coached employees on growth areas to enhance daily task performance and phone handling skills.
  • Utilized problem-solving skills to provide technical guidance and resources to associates.
  • Ensured accountability for call handling, resource utilization, and inventory management.
  • Collaborated with training department to verify accuracy and completeness of procedures.
  • Conducted call audits to maintain accuracy and quality standards.
  • Participated in regular leadership meetings to address staff performance and concerns.
  • Monitored performance metrics to assess team productivity and operational effectiveness.
  • Organized meetings with key personnel to discuss progress towards objectives.
  • Created process documentation and trained staff on new systems.
  • Developed training materials to support staff development and onboarding efforts.
  • Facilitated communication between departments to resolve operational challenges effectively.

Customer Service Rep III

Anthem, Inc.
Newbury Park
01.2008 - 01.2020
  • Assisted members, team members and management in resolving escalated issues within operational support queue.
  • Handled escalated issues by coordinating with appropriate departments for resolution.
  • Resolved customer inquiries through effective communication and problem-solving techniques.
  • Collaborated with associates to identify improvements in customer experience and operational systems.
  • Tracked and documented calls using computerized systems for efficient follow-up.
  • Asked probing questions to determine service needs and accurately input information into electronic systems.
  • Maintained accurate records of customer interactions in the company's database system.
  • Resolved member issues related to medical expenses through effective information gathering.
  • Effectively communicated with members regarding medical and prescription benefits, claims, and premium inquiries.
  • Updated member accounts to ensure accurate billing and payment processing.
  • Ensured adherence to DMHC guidelines during account reviews.
  • Trained new representatives on company policies and customer service best practices.
  • Identified areas of improvement in customer service processes and suggested changes accordingly.
  • Remained calm and professional in stressful circumstances and effectively diffused tense situations.
  • Developed strong customer relationships to encourage repeat business.
  • Performed administrative tasks such as filing paperwork, updating databases and generating reports.
  • Informed customers about billing procedures, processed payments, and provided payment option setup assistance.

Senior Recreation Leader

City of Oxnard
Oxnard
01.2006 - 01.2008
  • Attend weekly meetings.
  • Record journal entries and attendance.
  • Prepare for daily activities.
  • Report unusual instances to city staff.

Sr. Customer Service Associate

Walgreens Drug Store
Oxnard
01.2003 - 01.2008
  • Photo Technician.
  • Beauty Advisor.
  • Cashier and Stock.
  • Hallmark Representative.
  • Place orders to vendors, stocking, inventory, filing and arrange products according to schematic.

Recreation Services

City of Oxnard
Oxnard
01.2001 - 01.2008
  • Worked community service events.
  • Score Keeper for various sports.
  • Gym supervision.
  • Lifeguard (CPR & First Aid certified).

Education

Bachelors of Arts - Psychology

California State University Channel Islands
Camarillo, CA
01.2016

Associates of Arts Degree - Liberal Arts & Sciences

Oxnard College
Oxnard, CA
01.2008

Skills

  • Analytical and problem-solving skills
  • Regulatory compliance
  • Report generation
  • Claims processing
  • Process improvement
  • Conflict resolution
  • Workflow optimization
  • Performance evaluation
  • Case evaluation
  • Policy interpretation
  • Workload prioritization
  • Insurance policy knowledge
  • Relationship building
  • Organizational and time management skills
  • Leadership and accountability
  • Self-motivation and adaptability
  • Effective communication skills
  • Patient demeanor
  • Proficiency in Microsoft applications
  • Mainframe systems expertise
  • Callcare Browser proficiency
  • Solution Central knowledge
  • NextGen familiarity
  • Wellpoint Content Frameworks experience
  • OnDemand platform skills
  • ACMP understanding
  • Client Care Access expertise
  • Verint15 and Genesys Cloud proficiency
  • Concentrix knowledge
  • Client Online Services (COS) experience

Affiliations

  • Working out
  • Hiking
  • Team mom for children's sports
  • Reading

Accomplishments

  • Impact Awards for taking on additional tasks
  • Awards for great customer service
  • Continuous recognition as Exceeds Expectation on performance reviews

References

References available upon request.

Timeline

Grievance and Appeals Analyst Lead

Anthem Inc.
06.2022 - Current

Grievance and Appeals Analyst

Anthem Inc.
01.2021 - 06.2022

Operations Expert

Anthem, Inc.
01.2020 - 01.2021

Customer Service Rep III

Anthem, Inc.
01.2008 - 01.2020

Senior Recreation Leader

City of Oxnard
01.2006 - 01.2008

Sr. Customer Service Associate

Walgreens Drug Store
01.2003 - 01.2008

Recreation Services

City of Oxnard
01.2001 - 01.2008

Bachelors of Arts - Psychology

California State University Channel Islands

Associates of Arts Degree - Liberal Arts & Sciences

Oxnard College

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