Tanika Ranson

• Gather, analyze written provider request to determine if claim denial of no authorization can be overturned.
• Prepare response letters to provider appeals notifying them of approval or denial as well as status of appeal.
• Maintain files for provider to respond on individual appeals that lacked documentation for review.
• Checked documentation for accuracy and validity against submitted documentation in Icarepath.
• Maintained confidentiality of patient finances, records and health statuses.

• Trained and performed complex assignments of pprovider data loads through verification and analysis with utilization in NPAL website.

• Process overpayment adjustments for all medical claim types and all lines of business.

• researched provider contracts, verified fee schedules, using CMS and HSS pricing tools.

• Processed unsolicited refunds, identify systemic set-up issues or manual adjudication patterns for potential quality improvement and greater overpayment recovery opportunities.

• Loaded institutional and professional contracts into the Diamond System through research.

• Verified Institution associated DBA names through Nppes, researched facility ID in the American Hospital Directory and Qcor. As well as verified provider’s rates in Optum.

• Assisted with updating provider identification number to ensure no duplicates via special projects.

• Updated payable procedure codes, price rules and fee schedules for New York, Florida, New Jersey and South Carolina and Medicare lines of business.

• Resolved critical errors forwarded from the claims.

• Served as acting team lead and assisted as many as 15 new team members in the absence of my formal team lead.

• Investigated and adjusted claims requiring authorization, coordination of benefits, as well as member eligibility as well as improper configuration denials.

• Worked as liaison between Appeals and Claims Department to appropriately resolve provider disputes

• Processed claims in facets and analyzed claim denials, verified CLIA numbers in Webstrat.

• Analyzed claims through Projects with C.O.B and resolved escalations from providers via email and service forms.

•Researched member’s eligibility, benefits and verified primary insurance.

• Processed 250 provider HCFA and UB-92 facility claims per day in Florida, Washington, Kansas, Tennessee, Nevada and Kentucky markets.

• Processed 400 behavioral health claims for the Tennessee Market per day.

• Reprocessed and reviewed 200 claims on a small project up to 1,500 claims on a large project.

• Reviewed and routed 60-85 correspondence per day from providers and members through Macess.

• Assigned, loaded provider’s medical records and request for appeal into Nextgen database.

• Accurately interpreted and applied Medicaid contracts and fee schedules.

• Trained new customer service representatives and claims processors .

• Answered providers and members inquires concerning claim denials.

• Researched and analyzed claim denial, giving full explanation of denial and appeal process.

• Created file folder for provider correspondence according to company filing system.

• Manually processed 50-100 paper UB92 and HCFA 1500 mental/behavioral health claims.

• Adjusted and reprocessed 25-40 claims that were incorrectly denied, per provider’s request.

• Answered 50-60 inbound calls from member services and providers per day