Fatima Umbashi
Appeals and Grievances Specialist
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About
Dedicated Appeals and Grievances Specialist with 6 years of experience in healthcare conflict resolution, patient case analysis, and compliance management. Skilled in regulatory documentation and process improvement, with a strong commitment to HIPAA and CMS compliance. Recognized for streamlining workflows - achieving up to 90% efficiency gains in case resolution processes - and maintaining exceptional accuracy and attention to detail.
Experience
Appeals & Grievances Specialist - Community Health Systems - Sacramento, CA (Remote)
(2023-04 - 2025-06)
- Researched, reviewed, and resolved member and provider appeals and grievances in compliance with CMS, state, and organizational standards.
- Conducted detailed case investigations, including medical records and claims analysis.
- Drafted resolution letters ensuring accuracy, timeliness, and compliance.
- Collaborated with providers, clinical teams, and compliance officers to improve outcomes.
- Maintained meticulous documentation to support audits and regulatory reporting.
- Optimized workflows to improve case closure efficiency by 90%, reducing resolution timelines significantly.
Appeals & Grievances Coordinator - Maximus - Sacramento, CA (Remote)
(2021-04 - 2023-04)
- Handled escalated member complaints, ensuring prompt resolution per contractual and CMS requirements.
- Investigated medical necessity cases and collaborated with medical directors for final determinations.
- Supported audits by preparing accurate case files and compliance reports.
- Trained new staff on appeals processes and case management systems.
- Achieved 98% compliance in meeting case resolution deadlines.
Healthcare Customer Service Representative - Gainwell Technologies - Sacramento, CA (Remote)
(2019-10 - 2021-04)
- Served as first point of contact for members, educating them on benefits, claims, and appeal rights.
- Escalated unresolved issues to appeals and grievances department with complete case documentation.
- Maintained HIPAA compliance while handling sensitive patient information.
- Consistently exceeded KPIs for call resolution and member satisfaction.
Education
General Educational Development - GED - Sunrise Tech Center (2021 - 2023)
