Implement programs and initiatives to maximize the members experience. For Medicare, Commercial, and Medicaid members.

Medicare Advantage, Part D, Part C, Commercial, Medicaid, and SNP.

• Maintains systems and processes for timely and accurate resolution of all medical and administrative denials and appeals• Ensures compliance with NCQA, URAC, policies and procedures and other regulatory agency standards.• Works with physician advisor and attending physician in expediting appeals• Under the direction of the Director of Utilization Management and Clinical Operations, responsible for communication of decision letters for appeals to member and provider.• Provides educational training to staff, providers and members.• Assists in quality management projects, corporate audits, accreditation, and quality improvement activities.• Creation and review of audit files• Responsible for all reports related to the appeals process.

Responsible for investigating and reversing credit card charges disputed by the account holder in accordance to Visa/MC operating manuals.

Answer inbound customer service calls, provide data entry services for monetary and non-monetary transactions, entered new accounts, provide research assistance for clients and customers, monitor suspect activity on customers accounts.

Worked directly with clients in the field.Responsible for managing work sites.Marketing and sales spokesperson.

Assisted Coaching staff.Responsible for game preparation.Public Relations.Video