Appeals/Enrollment Specialist/Call Center Quality Auditor
Resume:
Debbie D. Clark
PO Box **** Troy, Michigan *****
******.*******@*****.***
Summary of Qualifications
Organized & detailed oriented
Work well independently & with others
Excellent written & oral communication skills
Proven leadership and multi-tasking abilities
Education:
Medical Billing: Jesse C. Kennedy School of Business Detroit. Michigan, 1994
New Horizons Computer Learning Center, Memphis Tennessee, 2001
University of Phoenix, currently enrolled
Computer Literate
Microsoft Word, Power Point, Excel and Publisher
Employment History
Claims Appeals Specialist, NGS CoreSource, December 2012-March 2013
Thoroughly investigated and analyzed medical and dental claims appeals. Resolved
issues, and made appropriate recommendations for adjudication or denial. Accurately
communicated the outcome with plan participates and providers via telephone and
mailed correspondence.
Quality Auditor, Molina Healthcare of Michigan, January 2009 – December 2012
Monitored member service/claims call center to ensure:
quality customer service
members have ease of access to entitled healthcare services and equipment
timely and efficient resolution of claims
Hedis alert advisements
Also provided training for current and newly hired staff and finalized their monthly
performance reports
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Debbie D. Clark
Enrollment Specialist, Molina Healthcare of Michigan, September 2006 - January
2009
Performed timely enrollment of new members into plans database and maintained for
accuracy and updates
Investigated case management files for non-compliant activity and prepared cases for
submission to MDCH for disenrollment consideration
Processed weekly eligibility reports and forwarded retro terminations to COB
department for financial recoveries
Processed data mining reports to monitor for those medically eligible for Children’s
Special Health Care Services (CSHCS) and maintained internal database
Submitted administrative disenrollment requests (deaths, out of states moves,
incarceration and foster care) to MDCH for disenrollment
Appeal & Grievance Coordinator, Molina Healthcare of Michigan, November 2005-
September 2006
Investigated, resolved & documented member and provider complaints.
Also obtained additional information, scheduled and facilitated provider and member
requested appeals and provided timely notification of the outcome
Member Service Representative, Molina Healthcare of Michigan, October 2004-
November 2005
Accepted incoming and placed outbound calls addressing member and provider related
inquiries and concerns
As a member advocate I educated clients while investigating and resolving benefit
related issues
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