La Twoise Haney

469-***-**** ad3bdo@r.postjobfree.com https://www.linkedin.com/in/la-twoise-haney-797b0a103/

Claims Manager

Seasoned Claims Manager renowned for orchestrating seamless claims processes and optimizing operational efficiency. Proven track record in mitigating financial risk through meticulous claim assessments and negotiations. Adept at implementing strategic initiatives to enhance claims handling, minimize turnaround time, and foster a customer-centric approach, ensuring client satisfaction and retention.

Key Skills

Rules and Regulations Staff Development Government Programs RCM Analytical Rural Health Billing

Project Management Commercial Insurance Provider Based Billing Health Insurance Medical Terminology

Professional Experience

Centene Corporation

Manager, Claims November 2021 – Current

Reviewed and identified root cause of Analyst claim errors from DMHC, CQI and Internal Audits. Provide feedback and coaching to the analyst.

Reviewed All Plan Letters (APL) and created efficient workflows for California Health and Wellness.

Evaluated and enhanced workflows to implement best practice and maintain policy and procedures for critical department functions.

Oversight of claims inventory to meet regulatory goal claims > 30 days at 1% and claims > 45 days at 5% of total inventory.

Daily inventory calls Supervisors and Team Leads to discuss day to day work objectives and priority assignments.

Collaborated with external and internal claims business partners to resolve complex issues and identify their processes.

Effectively distributed daily tasks to ensure compliance, service level agreements, and regulatory requirements were met.

Assisted in development of the annual budget for Claims Department.

Drove-quality change initiatives to meet overall goal of 85%

Oversaw team development, performance reviews, succession planning and growth conversation.

Evaluated risk and created a mitigation plan with a path to green date to showcase timely deliverables.

Weekly leadership meetings to review monthly interest accrued through aged claims over 45-days and assess future risk.

Zenith American Solutions

Manager, Claims March 2020 – November 2021

Measured and reviewed performance via KPIs and metrics.

Attended monthly Board of Trustees meetings to discuss current claims initiatives and member appeals.

Improved claims SLAs from 85% to 98.7% with 2 months of managing the department (SLA goal 90%).

Knowledge of Taft Hartley – Managed over 25 Union employees through the United States.

Knowledge of OE3 Summary Plan Benefits.

Adhere to Anthem Blue Cross Medical Guidelines for benefit coverage.

Worked hand in hand with Client Services to deliver the member experience.

Assigned, distributed, and monitored quality and quantity of work produced ensuring appropriate quality and production of internal service level agreements have been met.

Developed staff through performance management, goal setting, and effective employee relations.

Attended client meetings and interfaced with clients on claims-related issues to ensure client requirements and changes in benefit programs are implemented.

Assisted with development and documentation of departmental SOPs.

Oversaw vendor relationships.

Assisted with members eligibility.

Provided members with an explanation of benefits and details on open enrollment.

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Worked closely with Pension department regarding members eligibility hours and payout.

Worked with members and clients to resolve complex claims issues.

Upload additional documents to members file and process claims and benefits as appropriate.

Follow up to ensure the provider has received the application an uploading signed application once received.

Build relationships with Program Manager (PM) and support PM with tracking medical licensure and DEA request.

Updated Council for Affordable Quality Healthcare (CAQH).

Reviewed credentialing applications and follow up to obtain missing credentials/information.

Created provider credentialing records.

Conducted verification of provider credentials.

Medicare Operations Optum 360

Supervisor December 2013 – March 2020

Researched and compiled patients’ documents for Dignity Health Auditors.

Reviewed accounts for CMS838 Quarterly report, compile the data and send it to the facilities CFOs for signatures and review, and then send CMS reports to Medicare before deadline.

Reviewed and compiled Government Refund Log and report to Compliance by deadline.

Used Medicare and organization materials to train staff on processes and procedures.

Knowledge of Revenue Cycle Drivers and Revenue Cycle Workflow.

Knowledgeable of Total Quality Management (TQM), Project Management, and Lean & Six Sigma.

Demonstrated awareness in emotional intelligence as modeled in day-to-day leadership among peers.

Identified Root cause analysis to resolve claim issues and trends.

Remediated complex claims.

Ensured billing charges are captured.

Reconciled billing errors or omissions.

Reviewed patients account records and third-party issues.

Ensured accuracy of services provided review medical records to support the charges.

Knowledge of state/federal laws and regulations (EMTALA, JCAHO, OIG, CMS).

Maintained confidentiality of patients PHI with advanced knowledge on HIPAA laws and regulations.

Ability to collaborate and strategize effectively with co-workers and leadership.

Compiled daily cash reports for 19 facilities and report cash to leadership and management.

Strong job knowledge on all aspects of claims processing in PPO, Medi-Cal, and Medicare plans.

Pull batch reports.

Reviewed payment posting errors.

Post payments from batch reports.

Advanced knowledge on Medicare secondary, HMO, Medicare Advantage, Skilled Nursing LTAC, Home Health, UB04, and CMS 1500 forms.

Proficient in reducing defects and resolving claims to a zero balance.

Worked closely with compliance to ensure Medicare regulatory requirements were met.

Built employee morale, motivated and enhanced employee engagement.

Dignity Health

Sr. Patient Account Representative September 2012 – December 2013

Sutter Physician Services

AR Specialist May 2010 – September 2012

Health Net inc.

Medicare Part D Specialist July 2007 – April 2010

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Education

Master of Health Administration

University of Phoenix

Bachelor of Science (B.S.) – Health Administration

University of Phoenix

Achievements

Inducted in National Society of Leadership and Success – Sigma Alpha Phi

Certificate of completion for Rev Cycle Pro – Hospital Claims, Medicare

Continued Education Credits – AAPC

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