This resume is for SA-MECH C. ABRAMS, who has over 15 years of experience in the healthcare industry, specifically within managed care appeals and grievances. The resume outlines their educational background, which includes an associates degree in behavioral health and certification in human services. It also provides a detailed employment history working at Independence Blue Cross in various roles within the Medicare appeals and grievances department, currently as a supervisor, overseeing the handling of Medicare appeals in compliance with regulations. The resume demonstrates strong skills in organization, research, communication, and ensuring compliance.

1. SA-MECH C. ABRAMS
3843 N. 19th Street, Philadelphia, PA 19140
(267) 235-0481
samechsavoy@yahoo.com
PROFESSIONAL QUALIFICATIONS
♦ Microsoft Office♦Microsoft Word ♦Excel♦ Power Point ♦ Data Entry♦
♦Word Perfect♦ Acrobat Reader 9♦
Alphanumeric Filing♦Multi-Line Telephones♦
OBJECTIVE
To obtain a position within the healthcare industry that will enable me to use my strong organization skills, educational
background, and vast knowledge of managed care.
EDUCATION
2007 to Community College of Philadelphia Philadelphia, PA
2013 Behavioral Health Associates Degree
2007 to Community College of Philadelphia Philadelphia, PA
2013 Human Services Certification
1997 to Thompson Institute Philadelphia, PA
1998 Medical Office Management Certificate Awarded
PROFESSIONAL EXPERIENCE
2015- Independence Blue Cross Philadelphia, PA
Present Supervisor- Medicare Member Appeals and Grievances
 Supervise grievance specialists, who process Medicare managed care member grievances in
accordance with established policies.
 Proactively schedule associates to achieve daily work processing time frames and priorities,
tracks problem trends and issues, and facilitates resolution as required.
 Oversees the handling of Medicare Part C and Medicare Part D grievances in compliance with
CMS and corporate guidelines.
 Monitors unit performance for accurate and timely completion of assigned tasks.
 Facilitates effective operations and seeks to improve performance through training, coaching, and
process improvements.
 Collaborates cross-functionally within the department and externally to improve operations and
outcomes for our members.
 Facilitates the required research to resolve internal and external customer issues and problems
that are deemed sensitive.
 Submits timely and accurate daily, weekly and monthly reporting to management, including
maintenance of historical references in compliance with standards of production and quality.
 Coordinates with Quality Assurance team to identify repetitive and/or significant errors, developing
corrective action plans for improvement realization
 Coaches, encourages excellence, and develops staff potential to maximize individual and
departmental performance.
 Allocates work of unit personnel, conducts associate performance sessions, authors monthly
performance sessions and yearly appraisals and oversees the training of staff.
 Identifies and implements opportunities to improve interactions with other areas, and to improve
overall department and corporate performance.
 Ensures unit achievement of established performance objectives, and assists peers with support
as needed.
 Other duties as assigned.

2. 2014-2015 Independence Blue Cross Philadelphia, PA
Team Lead- Medicare Member Appeals and Grievances
 Work with management team and monitor the daily activities of appeal specialists, whose primary
responsibilities are investigating and completing member appeals
 Ensure appeal case files are completed according to CMS, Maximus, and departmental guidelines
 Quality assurance review of case files and render administrative decisions
 Quality assurance review of case files for external review
 Represent Medicare Advantage Plans in Administrative Law Judge hearings
 Prepare case files and participate within CMS audits
 Assist appeals specialist with daily case file activities
2007-2014 Independence Blue Cross Philadelphia, PA
Appeals Specialist- Medicare Member Appeals and Grievances
 Investigates Medicare member appeals for both standard and expedited requests
 Serve as the member’s advocate for medical and pharmacy appeals
 Prepare and investigate case files within CMS compliance timeframes
 Organize case files for external review per regulatory guidelines
 Case preparation for Quality Insights Organization appeals
 Produce decision letters and effectuations of claims regarding decisions rendered
 Knowledge of Part D standard and expedited appeals
2006-2007 Independence Blue Cross Philadelphia, PA
Appeals Intake Specialist- Medicare Member Appeals and Grievances
 Create files for incoming appeal and grievance requests
 Verify member eligibility
 Complete acknowledgement calls to members and providers
 Prepare and send acknowledgement letters
 Document Member Appeals System database and INFO
 Triage appeals and grievances to assigned specialists
2002-2006 Independence Blue Cross Philadelphia, PA
Care Management Assistant-Care Management and Coordination
 Crossed trained to handled pre-certifications for durable medical equipment and home health.
 Covers the telephone queue line to take messages and distribute calls to the appropriate departments
 Handles pended cases from the Navinet Ancillary task list
 Refers appropriate cases to the Care Management Coordinator
 Corresponds with contact persons of various home health agencies and durable medical equipment
providers