Claims Specialist and Project Analyst Professional

DENEEN MARSHALL

Email: ******.********@*****.*** ~ Phone: 704-***-****

Experience

Vaya Health

Claims Specialist 10/22 – Current

Ensure prompt provider payments through claims adjudication workflow, reconciliation, and quality control measures to meet or exceed prompt payment guidelines.

Responsible for reconciling provider claims payments through quality control measures, and Vaya’s policies and procedures.

Process claims adjustments for correction or recoupment and coordinates the recoupment process to ensure payment is recovered for inappropriately paid claims.

Maintain provider satisfaction by handling provider inquiries; providing information and assistance; and answering incoming calls.

Resolving problematic claims and system training issues. Research and resolve eligibility issues, authorization, overpayments, recoupment, or other provider issues related to claims payment.

Review internal bulletins, forms, appropriate manuals and applicable revisions, and fee schedules to ensure compliance with established procedures and processes.

Attend and participate in workshops and training sessions to improve technical competence.

Other duties as assigned, including coverage of specific functions of other staff to assist the Department as work demands may dictate.

Cardinal Innovations Healthcare 05/12 –12/21

Claims & Benefit Administration

Claims Project Analyst 07/17 – 12/21

Research and aid in resolving software-related issues reported by business partners and/or providers regarding system functionality and performance.

Communicate clearly to business partners/providers final resolutions of issues reported.

Participate in regular meetings with business partners/providers to work through reported issues and discuss business processes.

Assist internal business partners and providers with configuration-related requests.

Record testing/research results and communicate effectively with the development team for successful system configuration.

Maintain a working knowledge of the software and business processes.

Travel to provider sites to troubleshoot claims/system issues as needed.

Create and manage the project delivery schedules for the various Claims initiatives.

Coordinate project meetings and hold team members accountable for delivery of project tasks.

Work closely with IT partners and lead functional teams supporting the adjudication system updates/changes.

Collaborate with IT partners on urgent tickets to ensure system updates are met within the current sprint.

Provide status reporting to management and respond to inquiries about projects.

Work with Business Solutions to ensure claims reports are implements that allow ease of use for staff.

Team Lead 07/14 – 07/17

Coach, train and assist in managing a team of six Claims Specialists to complete daily tasks.

Assist with facilitation of Staff Meetings.

Create workflows to improve claims processing and/or ticket volume.

Gather Claims data and Top Five Denials explanations from team when needed.

Monitor team’s Pending Feedback Tickets and assist with research and resolution.

Resolve escalated provider telephone calls from Claims Specialists.

Research claim denials and/or issues that are escalated by Claims Specialist.

Participate in interdepartmental meetings to improve processes.

Liaison between Claims and all Departments within Cardinal assisting with issues and determining potential fraudulent billing. Work closely with QM Specialists in deciphering claims issues.

Create and updating of SOP’s.

Work directly with Network and UM departments regarding provider contract compliance and authorizations.

Create HD tickets for potential CI issues and update team regarding the CI issues.

Assist the IT department with User Acceptance Testing for CI and PD platforms.

Attend on-site provider meetings in conjunction with Management to resolve complex denial issues.

Attend Provider Conference Call meetings to assist in resolving complex denial issues.

Research and complete monthly Quality Audits for Claims department.

Assist with special projects, Mercer, yearly internal audit, and other projects as assigned.

Review agency communications and staying abreast of changes that may affect providers in order to provide reimbursement guidance and answer questions. Scheduling and conducting individual contract provider meetings for claims review when necessary.

Maintain a working knowledge of the claims software to include enrollment, utilization management, claims adjudication, reimbursement tables and finance modules. Review monthly Medicaid General & Special Bulletins and adhering to changes. Observing HIPAA regulations.

Claims Specialist 5/12 – 7/14

Provide customer assistance to approximately 325 assigned providers.

Research and resolve unmatched clients/providers on the Claims Exception Report. Reprocess claims with prior authorization, extend billing days, retroactive Medicaid, clinician license updates, etc.

Identifying and researching overpayments due to billing errors and assessing need for corrective measures. Working directly with claims analysts on reconciliation processes for overpayments. Reviewing provider specific weekly reports for denial reasons. Notifying providers when they need to rebill claims relating to: Coordination of Benefits, Clients out of Catchment, etc.

Processing provider audit paybacks as identified by Quality Management Audit or Provider Self Audit. Notifying Quality Management when any unusual provider billing is identified for further review.

Verifying and updating eligibility for Medicaid and/or Third-Party carriers in conjunction with the Eligibility Department. Analyzing provider billing trends and issues. Assisting with remittance advice audits and other claims-related research.

Research and respond to assigned grievances. Enter provider concerns in provider concerns module.

Other projects as requested.

Connextions 07/10 –05/12

Customer Service Representative

Sold health insurance policies for United Healthcare in a call center environment.

Accessed various subject matter databases to assist members and potential clients with information on health and prescription drug plans, which included pricing and benefit information.

Knowledgeable in Medicare and Medicaid rules and regulations. Currently hold North Carolina State License in Life, Health and Medicare.

Education

Capella University, BS Management & Leadership

LaGuardia Community College, Business Administration

Skills: Proficient and advanced in MS Word, Excel, PowerPoint, Outlook. Proficient in SharePoint, CI (claims system), and NCTracks (State claims system).

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