Shanean Gamble
@shaneangamble
I am a seasoned appeals and grievances coordinator specializing in healthcare claims accuracy and provider and member relations.
United StatesWhat I'm looking for
I am a seasoned appeals and grievance coordinator with 12 years of experience in healthcare claims and patient relations.
At Optum, I oversee the full lifecycle of standard complaint and appeal resolution, conducting detailed research, compiling reports, and keeping providers and members informed.
Previously, as a Medicaid Claims Examiner (Lead) at MVP Healthcare, I processed physician and hospital claims with a 99.67% accuracy rate, managed team administrative functions, and supported complex payment coordination. Earlier roles in patient relations and claims processing strengthened my skills in insurance verification, referrals, and provider reimbursement.
I bring technical proficiency in ICD-10, CMS guidelines, NYS Medicaid/Medicare, and systems including Facets, EMR, Alturista, EmedNY, Web Portal, JP Morgan, iHealth, and NextGen, along with strong attention to accuracy, clear communication, and cross-functional collaboration.
Experience
Work history, roles, and key accomplishments
OPAppeals and Grievance Coordinator
Optum
Sep 2020 - Present (5 years)
Oversee end-to-end standard complaint and appeal resolution, ensuring thorough investigations and timely outcomes; compile research and reports from providers and members and coordinate clinical justification with physician advisors.
Medicaid Claims Examiner (Lead)
MVP Healthcare
May 2017 - Mar 2020 (2 years 10 months)
Evaluated and processed physician and hospital claims with a 99.67% accuracy rate, led claims team operations, coordinated payment processing, and managed timesheets and daily reporting.
Patient Relations Lead
ENT and Allergy Associates
Aug 2016 - May 2017 (9 months)
Managed insurance verification and referral acquisition while supervising patient relations agents to improve coordination between patients, providers, and insurance entities.
Claims Specialist
Affinity Health Plan
Apr 2015 - Jul 2016 (1 year 3 months)
Conducted investigations and adjustments of medical claims to ensure policy compliance and accurate provider reimbursement, managing claim transmissions and phone support.
Customer Service Representative
Cablevision
Oct 2011 - Jul 2015 (3 years 9 months)
Maintained detailed records of customer interactions, resolved billing inquiries, and cross-sold services to support customer retention in a high-volume environment.
Education
Degrees, certifications, and relevant coursework
HCHostos Community College
Health Management
Attended Hostos Community College studying Health Management; degree or completion status not specified.
Availability
Location
United StatesAuthorized to work in
Job categories
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