Melinda C.
Manager Appeals and Grievances, Healthfirst
- Role
- Manager Appeals and Grievance at Healthfirst
- Location
- Washington, DC, US
- LinkedIn followers
- 500 followers
About Melinda C.
Deep expertise in Medicare, Medicaid, ACA Marketplace, and Commercial health plans, with…
Experience
Manager Appeals and Grievance
Sep 2021 — Present · New York, NY, US
Established and led a dedicated Clinical Training Team to support the development and implementation of standardized training resources for the Appeals & Grievances (A&G) department.• Appointed as Program Manager for the Authorized Representative (AOR) team, responsible for strategic oversight and operational performance.• Oversaw all aspects of Appeals and Grievances operations across Medicaid, Medicare, and Commercial lines of business, including clinical case review and Quality of Care grievance resolution.• Designed and deployed comprehensive best practice tools and clinical education resources within the first 90 days of hire, which remain integral to daily departmental operations.• Led full-cycle talent management efforts, including recruitment, onboarding, training, coaching, and performance evaluation for a large clinical team.• Acted as a subject matter expert (SME) for A&G operations, collaborating with cross-functional departments to inform and align policy, process, and compliance initiatives.• Managed daily caseloads to ensure compliance with federal and state regulatory requirements, organizational service level agreements, and quality benchmarks.• Served as lead for the Quality of Care program, directing case review processes, root cause analysis, and reporting to support internal quality improvement initiatives.• Directed vendor management activities, including oversight of contractual performance, service delivery standards, and regulatory alignment.
Education
Delaware Technical and Community College-Terry
Nursing
Capital University
Bachelor of Science - BS
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