Open to opportunities

Shanean Gamble

@shaneangamble

I am a seasoned appeals and grievances coordinator specializing in healthcare claims accuracy and provider and member relations.

United States

Message

What I'm looking for

I'm seeking an Appeals and Grievances Specialist role to leverage 12 years in healthcare claims, drive accurate appeals resolution, collaborate with providers/members, and improve processes within a compliance-driven, patient-focused team.

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

Current

Appeals and Grievance Coordinator

Current

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.

EMeDNY Appeals Reporting

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.

Claims Processing Medicaid Team Leadership 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.

Insurance Verification Team Supervision Scheduling

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.

Claim Transmission Phone Support Compliance ICD 10 Coding

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.

Customer Service Cross Selling Customer Retention Communication Skills