Customer Service White Plains

KENDREA CUMBERBATCH-ALEXIS, MBA

WHITE PLAINS, NY 10603 C: 203-***-**** *******@*********.***

SUMMARY:

Professional with extensive significant experience managing the appeals process throughout the lifecycle of a case. Understands requirements and works closely with managers to identify risks. Consistently provides excellent customer service, strong attention to detail, possesses strong organizational skills, and meets deadlines.

EDUCATION:

Mercy University (Dobbs Ferry, NY)

Master of Business Administration (MBA) in Healthcare Management February 2023 GPA: 3.86

Relevant Coursework: Healthcare Systems, Healthcare Politics, Policy, and Management, Finance Management of Healthcare Institutions, Entrepreneurship & Innovation Honors: Delta Mu Delta Business Honor Society

Mount Saint Mary College (Newburgh, NY)

Bachelor of Science (BS) in Business Management

PROFESSIONAL EXPERIENCE:

CenterLight Healthcare PACE, (Bronx, NY) April 2025 – May 2025 Claim Appeals and Audit Specialist

Perform end to end claims appeals review process. Track appeals and process the appeals into timely and accurate resolution. Address any issue with management. Work with other key stakeholders in making sure the recommended resolution is aligned with company policies and State/CMS guidelines.

Ensure accurate logging and processing of refund checks in the database, facilitating expedited credit of returned monies and proper application of transaction by our TPA.

Perform in-depth claims audit to confirm that all medical claims paid and denied accurately. Address any findings and observations with management and TPA for possible configuration update and fixes.

Perform ad-hoc claims analysis to ensure compliance and identify areas for improvement.

Maintain a high level of customer service for both internal and external customers, addressing inquiries and resolving issues promptly.

Investigate suspense conditions to determine if system or procedural changes could enhance claim workflow and efficiency.

Analyze patient and medical information to identify Coordination of Benefits (COB), Worker's Compensation, No-Fault, and Subrogation conditions.

Validate Diagnosis-Related Group (DRG) grouping and (re)pricing outcomes presented by the claims processing vendor to ensure accuracy.

Coordinate with Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments.

Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations.

Compile and analyze claim reports for adjustments resulting from external providers, vendors, and internal inquiries in a timely manner.

Assist management with timely and accurate response to internal and external audit inquiries, including government agencies.

Other duties as assigned.

BronxCare Health System, (Yonkers, NY) April 2018 – April 2025 Appeals Associate

Maintained continuous dialogue with all Payers regarding the Clinical appeals process.

Assisted with IPRO agents on onsite review process.

Identified problems that impact on clinical appeals unit – participate in performance improvement activities and provide statistical reports as required.

Updated the appeal status report on a daily basis.

Monitored and follow-up with the clinical information being presented to Managed Care Organizations.

Received Payer communications from clinical team via email, update the care manager, and appeal status report.

Assisted the Director with the scheduling and conducting of monthly meetings with the staff of clinical appeals.

Conferred with the Director and/or designee in the evaluation of the review activity. OrthoNet LLC, (White Plains, NY) February 2010 - January 2018 Appeals Analyst March 2015 - January 2018

Managed the appeals process between OrthoNet and Care Management

Processed cases and payer responses in a timely manner.

Identified and resolved problems associated with processed cases, system functionality and made recommendations to management for improvement and/or resolution.

Completed and corrected information for all cases and rejection to identify training issues within the department.

Provided ongoing monitoring and evaluation that involved contracts between OrthoNet and manage care payers regarding utilization management.

Worked closely with management and contract assistant to ensure the timely completion of all appeal files for various payer plans.

Communicated with client-designated representatives as needed to proactively identify and resolve client issues.

Ensured the accuracy and completeness of information entered into the database.

Assisted in the identification and correction of inaccurate and incomplete information.

Participated in the orientation of new staff members and assisted with training. Denials Coordinator February 2010 - March 2015

Maintained logs, calling and faxing to provider offices, verifying information, and entering data.

Worked with team to meet departmental goals to identify operational improvement opportunities and continuous process initiatives.

Developed and maintained denial records to assure that information is received, recorded, and filed in the appropriate manner.

Understood the general non-clinical terms of all OrthoNet cases to answer any questions a provider may have regarding a request.

Performed trend analysis for the Medical Directors to determine non-certification and documentation deficiencies throughout the organization.

Maintained confidentiality with HIPPA regulations.

Translated performed services into CPT codes for insurance companies. Gen Re, (Stamford, CT) May 2009 - September 2009

Records Specialist

Migrated claim files from spreadsheets to in-house database.

Created Whole-Box storage in accordance with department policies including preparation in Microsoft Excel, file organization, and performing all necessary steps.

Telephone followed-up with customers on outstanding claims. Day Pitney LLP, (Stamford, CT) November 2007 - March 2009 Records Specialist

Managed data entry of records information into numerous departmentally specific databases.

Maintained integrity of file structure, inventory, and allocation of workrooms.

Accurately manifested all services requests within strictly defined parameters.

Generated summaries of files checked out to personnel and reconciling file custody.

Developed myriad research strategies to address difficult attorney requests.

Acted as a contact point for internal customers and other departments. COMPUTER SKILLS:

Microsoft Office (Excel, Word, Outlook, PowerPoint), Allscripts, CarePort, Care Compass

Contact this candidate