Quality Assurance Continuous Improvement
Resume:
Tia Adams
**** ********** ******, ******, ** ****5
*********@*****.*** 469-***-****
Professional Summary
Detail-oriented and highly driven healthcare operations professional with over 10 years of progressive experience in claims adjudication, appeals and grievances, provider relations, and Medicare/Medicaid member support. Proven ability to navigate complex regulatory landscapes, resolve escalated issues, and optimize operational efficiency. Recognized for delivering one-call resolutions and driving continuous improvement in quality assurance and audit readiness.
Core Competencies
Claims & Benefits Analysis
Appeals & Grievance Resolution
Medicare / Medicaid Compliance
Provider & Member Relations
Quality Audits & Investigations
EMR & Claims Processing Platforms
Cross-Functional Collaboration
CRM, QNXT, PEGA, Availity, Webstrat, Encoder Pro, CRM
Microsoft Office, Adobe, Cisco WebEx, Citrix, Kronos, Avaya
Professional Experience
Senior Engagement Specialist
Molina Healthcare – Dallas, TX Dec 2023 – Sep 2024
●Delivered tailored Medicare support to members, ensuring full benefit access and issue resolution.
●Coordinated transportation and care access, enhancing patient satisfaction and plan compliance.
●Resolved billing discrepancies and processed real-time profile updates with high accuracy.
●Maintained regulatory compliance while supporting members through complex benefit structures.
Claims Portal Representative (Provider Claims)
Molina Healthcare – Dallas, TX Aug 2022 – Dec 2023
●Researched and resolved complex provider claims across multiple systems.
●Led multi-department audit and claims resolution projects based on business needs.
●Developed appeal resolutions using clinical review standards and payer policies.
●Prepared detailed reports and captured critical claim data to support audit readiness.
Appeals & Grievances Analyst – Provider Inquiry Research
Molina Healthcare – Dallas, TX Nov 2019 – Aug 2022
●Resolved provider disputes by evaluating claims against contract terms and fee schedules.
●Identified root causes of payment discrepancies and authorization denials.
●Facilitated coordination with internal departments for complex case escalations.
●Ensured all resolutions aligned with CMS and DOI regulatory standards.
Appeals & Grievances Specialist – Member Support
Molina Healthcare – Dallas, TX Jan 2016 – Nov 2019
●Handled escalated Medicaid and Marketplace appeals, delivering timely and compliant resolutions.
●Partnered with leadership and compliance teams to resolve high-impact complaints.
●Conducted in-person outreach to members, improving experience and reducing recurrence.
●Audited claim files and documentation to ensure accurate benefit payouts.
Customer Service Representative
Molina Healthcare – Dallas, TX Jul 2014 – Jan 2016
●Provided one-call resolution for claims, benefits, and health plan inquiries.
●Educated members on benefit structures, eligibility, and out-of-pocket responsibilities.
●Conducted demographic updates and provider searches to support rural-area accessibility.
Education
Bachelor of Science in Organizational Management
Paul Quinn College – Dallas, TX 2005
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