Senior Quality Control Analyst
Resume:
DAWNA LEAMON
North Richland Hills, TX *****
*****.*******@*****.***
Professional Summary
Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. To seek and maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Successful at reviewing suspicious activities and uncovering fraud. Excellent reporting and documentation skills. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Knowledgable and dedicated customer service professional with extensive experience in health insurance industry. Solid team player with positive demeanor and proven skills in establishing rapport with clients. Motivated to maintain customer satisfaction and contribute to company success. Specialize in quality, speed and process optimization. Articulate, energetic, and results-oriented with exemplary passion for developing relationships, cultivation partnerships and growing businesses. Hard working, self sufficient, highly motivated with 32 years in the health insurance industry. Easily adjusts to changes in workplace environment and procedures.
Microsoft Office, Microsoft Word, Excel. Proficient in medical terminology, contract language and state mandates. Processed claims in AS400 and RIMS settings. Quality Control. ICD-10. Insurance Verification. Medical Records. ICD-9. Improvement recommendations. Deductive reasoning. Data Analysis. Consultative support. Quality Processes. Call monitoring. Quality Assurance. Atliassan. Verint. Five9. AS400. Work Experience
Quality Assurance Analyst
UnitedHealth Group-Minneapolis, MN
November 2016 to May 2023
· Audit large dollar, exclusion, waiting period and pre-existing investigation claim files for review, release or referral to Upper Management
· Listen to customer service calls to determine if quality guidelines were followed
· Refer to Management for review and to take proper action to correct the issues as necessary
· Weekly meetings with Department Managers to discuss findings of call monitoring and Excel reporting
· Excel reporting of training opportunities for different Departments
· Premium handling
· Medical records review
· Processed unclaimed funds checks for Members and Providers. Reissued them to correct addresses.
· Supported company in maintaining work environment focused on quality, communication, collaboration, integration, and teamwork
· Created and achieved product quality objectives and met product specifications
· Mentored and coached team members on QA topics and strategies
· Assisted teammates in developing skills necessary to grasp application concepts
· Wrote and maintained detailed internal documentation on developed systems Claims Risk Analyst
US HealthGroup-Fort Worth, TX
September 2015 to November 2016
• Begin pre-existing investigations on potential Member's wishing to upgrade their benefits
• Review phone logs by Upgrade Analysts to retrieve information regarding medical conditions and physicians seen
• Request claim forms from Members, medical records from physicians and facilities to begin investigations
• Follow up with requests (via phone, fax, US mail) to Members, physicians and facilities
• Determine eligibility of Upgrades
• Forward to Claims Analysts for processing
• Investigated allegations to check validity and recommend actions to minimize risk
• Produced and filed reports to inform senior management of current activities and progress with investigations
Customer Service Analyst
US HealthGroup - Assumed By UnitedHealth Group-Fort Worth, TX February 2013 to September 2015
· Answer telephone calls from Members, Providers and Agents in regards to coverage, premiums and claims status and processing
· Audit claims processed by claims analysts
· Request check tracers on outstanding claim payments
· Process cancellations on policies (Paid to date and pro-rated)
· Work in a timely and efficient manner to complete telephone calls
· Provided primary customer support to internal and external customers
· Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns
· Answered product and service questions, suggesting other offerings to attract potential customers
· Answered constant flow of customer calls with minimal wait times
· Consulted with outside parties to resolve discrepancies and create expert solutions
· Investigated and resolved customer inquiries and complaints quickly
· Developed highly empathetic client relationships and earned reputation for exceeding service standard goals
· Maintained up-to-date knowledge of product and service changes
· Met customer call guidelines for service levels, handle time and productivity
· Followed-through on all critical inter-departmental escalations to increase customer retention rates
· Delivered prompt service to prioritize customer needs
· Work in a timely and efficient manner to complete telephone inquiries Education
High school diploma
Richland High School-N Richland Hills, TX
September 1985 to May 1988
Skills
• Quality control
• Customer service
• Internal Audits
• Typing
• Insurance verification
• Microsoft Excel
• Medical terminology
• ICD-10
• Windows
• Anatomy Knowledge
• HIPAA
• Basic math
• Mentoring
• Auditing
• Computer skills
• Risk management
• AS400
• ICD-9
• Microsoft Office
• Quality assurance
• CPT Coding
• Time management
• Medical records
• Microsoft Word
• Clerical experience
• Customer retention
• Data management
• Editing
• Anatomy knowledge
• Data analysis skills
• Customer support
• Organizational skills
• Training & development
• Quality management
Links
linkedin.com/in/dawna-leamon-621563240
Certifications and Licenses
Medical Terminology
Driver's License
November 2022 to November 2030
Additional Information
Will explain absence of work history after May, 2023 if necessary. It is a personal matter.
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