Open to opportunities

Caitlin Peterson

@caitlinpeterson

Message

Grievance specialist who resolves complex claims through data-driven, compliant care.

United States

Message

What I'm looking for

I’m looking for a role where I can use claims analysis, root-cause methods, and strong regulatory focus to deliver accurate, member-friendly resolutions while partnering with cross-functional teams to improve processes.

I’m a Grievance Specialist in the Grievance and Appeals Department, focused on resolving member complaints with accuracy, speed, and compliance. I conduct root-cause analysis on complaints, prepare for audit teams, and implement corrective actions alongside proactive education.

I review complex claims by analyzing EOBs and detailed bills, then research root causes to drive prompt, compliant resolutions communicated with members. I also develop member notifications using simplified language to ensure alignment with regulatory, accreditation, and accuracy standards.

Before this, I worked as a Health Outreach Specialist in the Case Management Department, where I audited patient charts for compliance gaps and identified eligible individuals for proactive outreach. I advocated for members regarding program benefits, and I initiated, authorized, and documented enrollment into specialized case management programs based on needs assessments.

Earlier in my career, I served as a Nutrition Care Manager and Nutrition Services Specialist, including roles supervising therapeutic diets and serving as a key audit contact while reporting findings to senior leadership. With a Master of Science in Public Health (Concentration in Public Health Nutrition), I bring an evidence-based, data-informed approach that centers on clear communication, accountability, and outcomes.

Experience

Work history, roles, and key accomplishments

Current

Grievance Specialist

Current

Essence Healthcare / Lumeris

Sep 2022 - Present (3 years 8 months)

Conduct root-cause analysis on member complaints and manage grievance and appeals by reviewing EOBs and detailed bills to drive prompt, compliant resolutions. Prepare audits, implement corrective actions, and develop member notifications in simplified language while ensuring regulatory and accuracy compliance.

Root Cause Analysis Claims Analysis Regulatory Compliance Grievance And Appeals Customer Service Salesforce Onbase

Health Outreach Specialist

Lumeris, Inc.

Jan 2022 - Sep 2022 (8 months)

Audited patient charts for compliance gaps and identified eligible individuals for proactive outreach. Advocated for members regarding program benefits and initiated, authorized, and documented enrollment into specialized case management programs in line with regulatory and internal audit standards.

Case Management Patient Chart Audits Regulatory Compliance Documentation Epic Patient Advocacy

Nutrition Services Specialist

Senior Resources of Guilford

May 2021 - Oct 2021 (5 months)

Monitored community nutrition programs to ensure adherence to state and federal nutritional standards and standardized data collection for consistent reporting. Educated and streamlined the Restaurant Voucher Program for qualified individuals to support program participation and compliance.

Compliance Reporting Monitoring Educational Programs Restaurant Voucher Program Quality Control

Nutrition Care Manager

Salemtowne Retirement Community

Feb 2016 - May 2021 (5 years 3 months)

Served as key contact during audits, collaborating with the interdisciplinary team to develop systems and policies and reporting findings to senior leadership. Supervised regulatory adherence for therapeutic diets and food sanitation while educating residents on healthy nutrition practices.

Regulatory Compliance Audit Coordination EHR Interdisciplinary Collaboration Leadership Excel