• Conducts extensive reviews of complaint and appeal cases to determine applicability of, and compliance with, federal and state regulations, enterprise policies and procedures and all related accreditation standards.• Reviews cases to assess whether they were appropriately handled as a clinical or administrative request and was correctly processed to avoid prompt pay penalties.• Evaluates urgency of clinical situation to assess appropriate handling, determine if sufficient records were obtained, and review medical records and medical policies to determine if correct criterion has been utilized in each review.• Reviews case documentation to assess appropriate system entries have been made and that the step-by-step process is sufficient to mitigate risk associated with regulatory reviews, accreditation reviews, and potential litigation.• Assists management in process improvement strategies to achieve business objectives.• Prepares audit findings and recommendations for G&A associates and management on a monthly basis.• Identifies and communicates error trends to improve overall quality of enterprise G&A team.

• Responded to appeals in English and Spanish, adhering to all regulatory, accreditation and internal processing timelines ranging from 72 hours to 60 calendar days.• Conducted extensive research through pertinent claims and obtained medical records to route to nursing and/or medical staff for review and determination. • Served as a liaison between grievances & appeals, medical management, legal, service operations and other internal departments. • Responsibilities excluded conducting any utilization or medical management review activities which require the interpretation of clinical information. • Identified opportunities for improvement and provided any support and assistance to G&A Analyst I associates as needed.• Provided occasional assistance by conducting in-depth investigations involving issues with benefits, eligibility, billing, fraud, discrimination, services, or clinical malpractice, as a result of a physician's office, hospital/facility, pharmacy, or the health plan.

• Responded to complaints in English and Spanish, adhering to all regulatory, accreditation and internal processing timelines ranging from 24 hours to 30 calendar days.• Conducted in-depth investigations involving issues with benefits, eligibility, billing, fraud, discrimination, services, or clinical malpractice, as a result of a physician's office, hospital/facility, pharmacy, or the health plan.• Triaged through a high inventory based on the severity of the complaint and the urgency of the member's need for care.• Used telephonic tools, disk operating systems (DOS), and Microsoft Access databases to efficiently store, prioritize, and resolve complaint investigations.• Served as a liaison with several internal departments and contracted care providers through email and fax communications.• Conducted verbal and drafted written communications to affected health plan members to provide a complaint resolution.• Trained and mentored new hires, optimizing team efficiency.• As a subject-matter expert, successfully resolved highly important complaints from external agencies, such as the Agency of Healthcare Administration (AHCA) and the Centers for Medicare and Medicaid Services (CMS).

• Responded to and resolved, on the first call, customer service inquires and issues in English and Spanish by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, financial spending accounts and correspondence.• Guided and educated members (mostly seniors or individuals who qualified for the Medicare program) about the fundamentals and benefits of consumer-driven health care topics to select the best benefit plan options, maximize the value of their health plan benefits and choose a quality care provider.• Initiated proactive outreach to members as needed, which involved welcoming new members to our health plans, addressing gaps in care, reviewing coverage, and referring or enrolling them to internal specialists and programs based on their needs and eligibility.• Contacted care providers (doctor’s offices) on behalf of the member to assist with appointment scheduling or connections with internal specialists for assistance.• Assisted members in navigating myuhc.com and other UnitedHealth Group websites.• Maintained thorough documentation of each caller interaction to meet personal metrics and ensure compliance with quality standards.• Trained peers in the organization on the Web Support and House Calls programs, equipping them with the necessary skills to fulfill their daily responsibilities.• Joined the South Florida Escalation Team in April 2020, where utilized Microsoft SharePoint and Access database to record and process escalated cases from peers.• Assessed call recordings from peers to ensure all concerns were addressed, on the first call, providing constructive feedback to their immediate leaders when necessary.