Data Entry Quality Assurance

TANESHA ORANGE

*************@*****.*** / C: 215-***-****

Jacksonville, FL 32210

SUMMARY

I am passionate about advocating for others and I find fulfillment in helping people achieve their goals. This is why I have chosen a healthcare career. My goal is to be a reliable source of knowledge, understanding, and motivation for others to make the best decisions for themselves and their communities. I measure success by my ability to positively influence those around me. I am excited about the prospect of contributing to your company in a way that is both fulfilling and rewarding. I am always striving to improve and never content with stagnation. I take pleasure in generating new ideas that lead to positive change and hope to leave a legacy for others to follow.

SKILLS

Independent Worker

Multitask effectively and efficiently

Critical Thinker

Innovative problem-solver who can generate workable solutions and resolve complaints

Hard working, focused, and highly motivated professional

Excellent communication (listens attentively, speaks effectively, writes clearly and concisely)

Computer Skills in Microsoft Word, Outlook, Excel, PowerPoint

Researching and Organizing with a high degree of detail orientation

Data Entry

EXPERIENCE

Appeals Associate for Medicare Appeals & Grievances/ Blue Cross Blue Shield of North Carolina- Remote 08/2023 –

Responsible for the thorough analysis, research and completion of Medicare appeals and grievances within the company.

Address all customer concerns and ensure timely and complete resolution and satisfaction.

Ensure timeliness, quality, and efficiency in all work to comply with applicable mandated State and/or Federal legislative or regulatory requirements, National Committee for Quality Assurance (NCQA) standards, and BCBSNC policies and procedures.

Analyze claims to ensure proper processing following the member's plan benefit levels.

Collaborate with vendors and internal contacts to ensure that member benefits are used and delivered effectively.

Forged sustainable rapport with providers and members through education on Medicare policy and guidelines, as well as member’s specific plan benefits.

Complaint and Appeal Liaison for Medicare (Part C) / Aetna Inc., a CVS Company - Remote 01/2019 – 08/2023

Capitalized on opportunities to enhance member and provider experiences by offering optimal levels of service daily.

Excelled in exceeding departmental goals per CMS and federal guidelines.

Resolved service problems by clarifying member or provider complaints and determining optimal solutions.

Provided excellent services to members and providers by following up on issues, concerning a denial of medical or prescription coverage.

Communicated with members and providers via email, fax, or phone to ensure that appropriate information and clarity were given to ensure the best decisions were being made for the member's medical care.

De-escalated problematic customer concerns, maintaining a calm, friendly demeanor.

Investigated all complaint and appeals issues using knowledge base and personal experience to complete timely resolutions.

Provided advice through work groups and committees to improve team, service, and procedural standards.

Prevented compliance concerns by researching discrepancies and taking corrective actions.

Cultivated impactful relationships with members and providers that drove business development by delivering product knowledge.

Created and implemented process improvements to reduce workloads and bolster job efficiency.

Delivered fast, friendly, and knowledgeable service for routine questions and service complaints.

Worked independently on a strict timeframe.

Triage Coordinator for Medicare Services-Part D / Aetna Inc., a CVS Company - Blue Ball, PA 05/2016 - 12/2018

Reviewed all incoming appeal requests received for the day from the various intake methods for priority, requester, and determination of valid part d drug.

Checked the appropriate systems for any Part D drug denials, reimbursements, and coverage determinations denials.

Rerouted to the appropriate area for processing- possible (commercial member request, commercial Rx group member, MA-Only plan member, or possible HIPAA violation requests

Researched any issues about possible Out-of-compliance requests, IRE requests, IRE decisions, ALJ, and MAC notices and routed them to the appropriate department for resolution.

Triaged incomplete components of complaints/appeals to appropriate subject matter experts within another business unit(s) for resolution response content to be included in the final resolution response.

Department lead for quarterly newsletter and Moral/Activities Committee

Complaint and Appeal Analyst for Part D Medicare / Aetna Inc., a CVS Company - Blue Bell, FL 10/2014 - 05/2016

Coordinated effective resolution of member or provider/practitioner appeals.

Managed to resolve complaint/appeal scenarios for prescription drug products, which may contain multiple issues and may require coordination of responses from multiple business units.

Ensured timely, customer-focused response to complaints/appeals.

Identified trends and emerging issues and reported and recommended solutions.

Identified and researched all components within member or provider complaints/appeals for all products and services.

Coordinated all components of complaints/appeals including final communication to member/provider for final resolution and closure.

Assured complaints/appeals were handled within the established timeframe to meet company and regulatory requirements.

Identified trends or emerging issues and gave input on potential solutions through knowledge of member and provider appeal policies.

Developed strong analytical skills focusing on accuracy and attention to detail.

Perfected excellent verbal and written communication skills

Met the demands of a high-paced environment with tight turnaround times.

Made appropriate decisions based on Aetna's current policies/guidelines.

Member Services Representative for Medicare Serv / Aetna Inc., a CVS Company - Blue Bell, PA 10/2012 - 10/2014

Became proficient in healthcare terminology and dynamics of the healthcare profession.

Provided integrated health information to drive informed decision-making.

Managed multiple priorities.

Aligned work to strategy using the Aetna Way values.

Embraced change.

Demonstrated cross-cultural sensitivity.

Understood the member's point of view.

Collaborated with associates to create value for constituents.

Resolved conflicts while maintaining good member relationships.

Managed integrated service delivery.

Department Lead for Blue Bell Medicare Member Services Operations Employee Engagement Committee.

Culture Advocate.

Assisted with the planning and implementation of quarter employee celebrations.

Focus group member who assisted in the implementation of a Claims Helpdesk for Medicare Member Services Operations.

Collections Representative / WELLS FARGO BANK Chester, PA 01/2010 – 09/2011

Collected on overdrawn checking and savings accounts for Wachovia and Wells Fargo Bank customers.

Handled transferring of funds; credit and debit transactions and checks from customers to pay on overdrawn accounts.

Data Entry.

Organized team-building events for my department.

Team Lead for the United Way Fundraising Campaign for my department.

Team member of Social Responsibility Committee for Wells Fargo ODCR Chester County Division.

Customer Service Representative / SRC an AETNA COMPANY Columbia, SC 10/2007 – 5/2008

Enrolled members in health insurance benefits.

Answered any questions or concerns dealing with insurance benefits and policies.

Data Entry.

Service Coordinator / NCR West Columbia, SC 01/2004-10/2007

Assigned work orders to customer engineers in the Northeast portion of the United States.

Coordinated best travel routes, and prioritized handling of work orders for the customer engineers.

Managed the workload of each customer engineer and matched skills with customer needs.

Completed multiple reports to ensure company and customer expectations were met.

Data Entry.

EDUCATION AND TRAINING

Florida Technical College– Online Medical Billing and Coding Graduated 02/29/2024.

National Certified Insurance and Coding Specialist certification Completed 02/2024

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