KIMBERLY ALEXANDER
St. Peters
Summary
Professional with extensive experience in managing Commercial Insurance Clinical Appeals processes within healthcare sector. Known for strong analytical skills, effective communication, and ability to navigate complex regulatory environments. Proven track record in fostering team collaboration, adapting to changing requirements, and achieving results. Well-versed in conflict resolution, data analysis, and workflow optimization. Reliable and adaptable with focus on delivering high-quality outcomes.
Overview
11
11
years of professional experience
1
1
Certification
Work History
CLINICAL APPEALS COORDINATOR
United Health Group
10.2023 - Current
- Assisting with Commercial/Employer plans Clinical Appeals, recognizing, processing and prepping all denied authorizations withing a production environment.
- Coordinated appeals processes to ensure compliance with regulatory requirements and organizational policies.
- Prepping and preparing medical documents for medical appeals to send for review from clinical team.
- Knowledge of medical jargon, policies, Medicare and Medicaid rules and regulations.
- Verifying the eligibility of a patient’s current insurance for dates of service which is being appealed.
- Verifying codes being appealed, retrieving any and all benefit language that is required for denied benefits, compiling any and all medical policies that apply to the denied services.
- Ability to multitask and take on different projects.
DUAL SPECIAL NEEDS PLAN COMPLEX CARE NAVIGATOR
United Health Group
01.2021 - 10.2023
- Assisting Dual Special Needs plan members in a specific state to coordinate all their healthcare needs and to assist with scheduling doctors’ appointments, transportation rides to and from doctors’ appointments or pharmacy. Helping members to understand bills from providers and understanding the Medicare/Medicaid plan process of claims, understanding and reviewing medical and prescription claims and how they were processed and reviewing of the claim to educate and limit the need for routing for further review.
- Contacting providers and vendors daily on behalf of members, verifying Medicaid eliigibility, making any type of phone calls or using the members plan benefits. Locating and identifying the need for resources to help and assist members with social determinants of health, placing orders for the over-the-counter benefits. Scheduling house calls visits, and an overall dedicated single point of contact for members to have a first call resolution and a more personable hassle-free experience while helping the members to be able to focus more on their personal needs and complex medical needs with a hassle-free experience with their Medicare/Medicaid plans.
RESOLUTION SUPPORT SPECIALIST
United Health Group
01.2015 - 01.2021
- Customer Service Advocate provided first-call resolutions for members’ issues following appropriate processes. Assisted as a call back-up associate for heavy call volume, as needed.
- Supported all lines of business which included Medicare Advantage plans for East Coast and West Coast plans, Prescription Drug Plans, Employer Group, Senior Supplement plans as well as working in Government operations Medicare & Retirement
- Reviewed and submitted any type of billing, claims and compliance issues, enrollment status for members.
- Delivered exceptional customer support, resolving inquiries and issues efficiently.
- Facilitated communication between departments to address client needs and improve operational efficiency.
Front Line Customer Service Representative
United Health Group
07.2014 - 01.2015
- Responded to and resolved customer service inquiries and issues within Medicare Advantage plans including but not limited to Employer Group plans and Prescription Drug plans.
- Provided education and status on previously submitted pre-authorizations or pre-determination requests. Problems were solved, with support resources, and complex issues within multiple databases.
- Scheduled appointments on behalf of members and closing gaps in care, and getting first call resolutions.
- Resolved customer inquiries and complaints through efficient communication channels.
- Improved service response times by streamlining issue escalation processes.
- Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
Education
Associate of Science - Paralegal Studies
Hickey College
Maryland Heights, MO05-2003
Skills
- Proficient in Microsoft Word all levels, Windows PC applications
- Clinical appeals processing systems
- Medical acronyms and jargon
- Cpt Codes in Medical
- Adobe acrobat
- Excel
- Powerpoint
- Outlook
- Microsoft Teams
- Webex
- Regulatory compliance
- Medical documentation preparation
- Insurance verification
- Denial management
- Claims analysis
- Customer service excellence
- Complex problem resolution
- Healthcare coordination
- First call resolution
- Cross-department communication
- Medicare regulations knowledge
- Medicaid eligibility verification
- Patient advocacy
- Appointment scheduling
- Empathetic communication skills
- Billing inquiry resolution
- Social determinants of health awareness
- Customer service
- Active listening
- Critical thinking
- Data entry
- Customer relations
- Problem resolution
- Relationship building
- Call center experience
- Computer proficiency
- Conflict resolution
- Complaint handling
- Microsoft Excel
- Complaint resolution
- Payment processing
- Client relations
- Customer satisfaction measurement
- Professional telephone demeanor
- Call center operations
- Microsoft outlook
- Scheduling
- Follow-up skills
- Call management
- Documentation
- Administrative support
- Microsoft Office Suite
- Microsoft PowerPoint
- Data collection
Accomplishments
Resolution Support Specialist Team Star multiple months for meeting and maintaining Metrics.
Completed Certifications to handle all lines of business in Medicare/Medicaid Healthcare Insurance.
Completed training and certification for Medicare systems and verifying Social Security Benefits for Medicaid purposes.
Completed all required and mandated trainings for Medicare/Medicaid and Commercial Healthcare insurance Clinical Appeals.
Certification
- Medicare/Medicaid Medical Insurance Compliance Certified
- Medicare and Retirement Certification, Level 1&2
Timeline
CLINICAL APPEALS COORDINATOR
United Health Group
10.2023 - Current
DUAL SPECIAL NEEDS PLAN COMPLEX CARE NAVIGATOR
United Health Group
01.2021 - 10.2023
RESOLUTION SUPPORT SPECIALIST
United Health Group
01.2015 - 01.2021
Front Line Customer Service Representative
United Health Group
07.2014 - 01.2015
Associate of Science - Paralegal Studies
Hickey College