Fatima Umbashi

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.

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.

General Educational Development - GED - Sunrise Tech Center (2021 - 2023)