ATHINA D. FELTON

***** **** **** **

Florissant, MO 63034

314-***-**** - Cell

OBJECTIVE: Enthusiastic and dedicated professional competent in performing management responsibilities; as well as a leader that inspires cooperation among team members. Looking to secure a professional and challenging leadership position in an organization that holds the opportunity for advancement and allows the maximization of personal growth while achieving business goals.

RELEVANT WORK HISTORY:

Centene Corporation – St. Louis, MO July 2016 – Present

Project Manager III

Engage and lead cross functional teams and meetings

Develop processes and tools best suited for each assigned project while providing functional and technical knowledge across multiple businesses

Maintain detailed project documentation and effectively communicate status to all stakeholders

Manage the full project life cycle and monitor the creation of all project deliverables

Lead Risk Adjustment Coding Analyst

Develop and document coding related departmental policies and procedures

Serve as the Risk Adjustment Coding SME, Auditor, and Trainer for the team

Coordinate and update Share Point site to include all applicable team information

Collaborate with vendor on data extraction files and disputes

Sr. Risk Adjustment Coding Analyst

Review and analyze results of risk adjustment coding validation across multiple states to identify coding patterns and make necessary updates

Perform RADV audits, In Home Assessment Audits, and Vendor coding over reads

Identify any issues and determine impact to risk adjustment models

Report and communicate results for various product services in a summary report to leadership

Clinical Reviewer I

Recognize and intervene on fraud, waste, and abuse of specific diagnosis and services prior to appealing claims

Perform complex retrospective and prepayment reviews of medical records to identify potential abuse, waste, and fraud of inappropriate billing practices

Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, and regulatory state guidelines

Perform onsite audits in conjunction with investigators and managers

Washington University September 2012 – July 2016

Lead Medical Coding Appeals Analyst

Ability to review medical records to identify correct coding issues

Prepare and generate monthly quality auditing report,

Participate in meetings to discuss ongoing trends and issues regarding the administration of managed care contracts, while also having daily interaction and effective communication with providers, members, and other stakeholders.

Compile and submit high dollar appeals

Insurance Billing Coordinator III

Generate, review, and analyze reports for identified under allowed or low paid claims

Implement process for identifying under allowed or low paid claims using available tools

Verify applicable provider contracts to confirm correct claim payments

Develop appeal communication letters and submit to insurance carriers as a result of identifying underpaid claims

St. Louis University January 2004 – September 2012

Senior Reimbursement Analyst Assistant

Daily interaction and effective communication with providers, members, and other stakeholders

Provide pended claims resolution using root cause analysis

Assist Reimbursement Analyst with day-to-day operation (e.g. educating staff, identify revenue and trending issues, provide accurate reports regarding various University cycles and update dashboards)

Experience performing minimal SQL Query-writing functions

Per Se’ Technologies February 2002 – October 2003

Senior Billing Quality Auditing Specialist

Determine member eligibility and Maintain Provider Credentialing Data

Maintain and track contractual billing, registration, credentialing, and posting errors for department, while providing feedback results to management team

Ensure monthly HIPAA compliant regulations met by department

Coordinate audit results and department feedback to build and refine system tools and written tools

HNC Insurance Solutions October 1999 – January 2002

Claims Analyst Team Lead

Organize and Conduct ongoing staff training to ensure proficiency and technical competence

Maintain current knowledge of covered benefits and various contracts to develop company policies applicable to process workers compensation claims

Supervise and audit the performance of ten Claims Analyst as it relates to bill review functions, quality review, adjudication of payment, and state workers compensation claims payment regulations

Discuss/Educate providers and employers regarding the processing of worker’s compensation related claims

Magellan Behavioral Health May 1999 – October 1999

Claims Examiner

Familiarity with Managed Care, Medicaid, Medicare and other Government/State funded programs, PPO, U & C, Worker’s Compensation, and HMO fee guidelines to process behavior health claims

Determine member eligibility and Maintain Provider Credentialing Data

Track system claim edits that applied to incorrectly processed claims due to late claims submission

Communicate with IT workgroup to enhance system edit terminology

Metracomp, Inc October 1996 – February 1999

Referral Coordinator

Determine case management or medical appropriateness regarding precertification and referrals.

Initiate and track workers compensation member referral via notification report from employers

Document case management notes received from provider treatment report

Discuss/Educate providers and employers regarding worker’s compensation relations

Group Health Plan November 1993 – October 1996

Precertification Specialist

Determine case management or medical appropriateness regarding precertification and referrals.

Communicate referral status with member, medical management team, and local health plan

Confirm member eligibility

Compile and report all pre certifications initiated on a daily basis

EDUCATION:

Southern Illinois University Edwardsville, IL

Major: Health Informatics Graduation: 12/2020 – Master of Science

Webster University St. Louis, MO

Major: Health Administration Graduate: 05/2018 – Master of Science

St. Louis University St. Louis, MO

Major: Social Work Graduate: 05/2015 – Bachelor of Science

(Cum Laude)

American Academy of Prof. Coders Salt Lake City, UT

Certified Professional Coder July 2005 - Certificate

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