Quality Assurance & Claims Processing Specialist
Resume:
Culinary Arts:
Culinary
Remington College
High School Diploma:
Gateway Charter Academy
***************@*****.***
Forney, TX 75126
Core Competencies
• Medical terminology
• Compliance analysis
• Claims processing
• Quality assurance
• Documentation management
Customer relationship
management
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• Data accuracy verification
• Documentation processing
• Coverage determination
• Insurance plan verification
• Appointment scheduling
• Patient education
• Medication management
• Quality control
• Effective communication
• Data analysis
• Problem solving
• Attention to detail
• Software testing
• Regulatory compliance
• Auditing processes
• Team collaboration
• Time management
• Billing accuracy
• Patient documentation
• Project coordination
• Relationship management
• Documentation review
Education
Versatile and results-driven professional with expertise in office management, dispatch coordination, healthcare operations, behavioral support, and insurance claims. Known for exceptional organization, multitasking, and problem-solving skills, with a proven track record of improving workflows, resolving complex issues, and delivering high-quality outcomes. Compassionate and adaptable, skilled at fostering positive relationships, ensuring client satisfaction, and driving team productivity in fast-paced environments.
Firs Convenience Bank - Cash Management Specialist Dallas, TX
01/2021 - 12/2025
Cigna - Quality Assurance Specialist
Remote
01/2019 - 01/2023
Tonya Sparks
Professional Summary
Professional Experience
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Processed and reconciled daily cash transactions, including premium payments, refunds, and account adjustments
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Accurately applied customer payments to accounts while ensuring compliance with internal controls and company policies
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Investigated, identified, and resolved payment discrepancies and unapplied cash in a timely manner
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• Maintained detailed records and documentation for audit and reporting purposes Collaborated with internal departments to resolve billing and payment issues efficiently
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Met strict deadlines while handling high volumes of sensitive financial data with accuracy and confidentiality
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• accounting, and/ or financial balancing function Intermediate proficiency with Windows based software programs (i.e. MS Word, Excel)
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• Demonstrated ability to take independent initiative Solid analytical and multi-tasking skills that result in solid decision-making skills and time management
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Strong customer/client focus with the ability to resolve issues with a positive outcome
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Comfort working in a fast-paced, high-volume office setting with great attention to detail
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• Ability to demonstrate, comprehend and apply our workplace values.
• Managed daily cash flow and reconciled bank transactions. Lincare - Patient Intake & Documentation Specialist Dallas, TX
01/2018 - 01/2020
Strong knowledge of medical terminology, anatomy and physiology, medications, and laboratory values, applied accurately in daily workflow.
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Solid math skills, including addition, subtraction, multiplication, division, rate calculations, and percentage computations using whole numbers and decimals.
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• Typing speed of 40+ WPM, with high accuracy.
Proficient in the use of general office equipment, including computers, fax machines, copiers, scanners, and multi-line telephone systems.
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Experienced with Microsoft Word, Outlook, Excel, and internet-based applications.
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Excellent command of English grammar, punctuation, and professional written communication.
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Consistently follows management direction and detailed instructions with accuracy.
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Demonstrates strong attention to detail, quality control, and continuous improvement practices.
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Clear and effective communicator; conveys information accurately, listens actively, and seeks clarification when needed.
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• Works independently, with strong prioritization and time-management skills.
• Maintains strict confidentiality standards.
• Promotes a positive, team-focused work environment.
• Maintains focus and productivity in high-distraction settings. Performs effectively under pressure, and adapts well to change, delays, and unexpected situations.
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• Consistently follows company policies and procedures. Perform audits and quality checks on operational workflows, review documentation for accuracy and compliance, identify errors or discrepancies, and prepare quality reports.
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Reviewed and analyzed billing documentation to ensure accuracy and compliance with Medicare, Medicaid, HIPAA, and commercial insurance requirements.
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Collected and managed patient eligibility documentation including prescriptions, Certificates of Medical Necessity (CMN), Letters of Medical Necessity (LMN), and prior authorizations.
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Generated and processed electronic documentation request forms to obtain required patient records from physician offices.
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Coordinated with physician offices to obtain prescriptions, CMNs, LMNs, clinical notes, lab results, and supporting medical documentation.
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Communicated with insurance carriers to verify coverage and secure approved prior authorization requests.
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Requested and tracked authorizations from state Medicaid programs and other government payers.
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Resolved pending revenue issues by reconciling missing documentation and outstanding charges to prevent billing delays.
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Maintained and updated physician database records to ensure accurate billing documentation and provider communications.
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CVS Specialty Pharmacy - Specialty Pharmacy Technician Dallas, TX
01/2016 - 01/2018
Collaborated with physician offices, sales teams, and internal support departments to ensure timely and compliant documentation submission.
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Identified recurring account or provider documentation issues and escalated trends to management appropriately.
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Identified documentation trends and provided feedback and education to internal and external partners to improve compliance and processing efficiency.
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Served as backup support for Customer Service by addressing customer concerns, complaints, and account inquiries.
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Demonstrated strong organizational and time-management skills to manage high-volume workloads and ensure timely completion of assignments.
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• Met departmental productivity and quality performance benchmarks.
• Participated in continuous quality improvement initiatives.
• Promoted a collaborative, team-oriented work environment. Represented the organization professionally in all internal and external communications.
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Maintained consistent attendance and schedule flexibility to support operational needs.Manage prior authorizations for procedures or durable medical equipment
(DME).
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• Handle billing or claims submission for initial patient intake.
• Coordinate follow-ups and reminders for patients.
• Resolve discrepancies in patient information or insurance coverage. Facilitated patient access to prescription medications by serving as the primary liaison between patients, pharmacies, and insurance providers.
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Conducted benefits investigations and reviewed insurance coverage to identify financial assistance opportunities, and resolve formulary or copay issues.
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Collected and analyzed patient demographics, medication history, and insurance status to identify socioeconomic barriers, and determine eligibility for assistance programs.
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Developed expertise in payer reimbursement processes and third-party pharmacy claims to support efficient medication access.
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Educated patients, providers, and clinic staff on navigating complex insurance situations and next steps for obtaining coverage.
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Coordinated with external stakeholders, including PBMs, pharmaceutical manufacturers, pharmacies, and healthcare providers, to streamline access to specialty medications.
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Maintained strict compliance with federal and state regulations, while upholding the highest ethical standards.
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Improved the patient service experience by providing high-touch support, and ensuring timely access to medications.
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Performed additional duties as needed to support pharmacy operations and patient care.
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