Allie Caldwell

• Conducted independent claim determinations using contract provisions and state and federal regulations to identify improper payments and potential fraud, waste, and abuse.

Collected, collated, and analyzed claims and encounter data to detect aberrant billing patterns, and recommend corrective actions.

• Maintained detailed case documentation, and prepared summaries to support appeals, provider outreach, and potential regulatory reporting.

• Collaborated with clinical and professional staff to develop investigative strategies, and escalate complex cases for field review.

• Tools used: SQL, Power BI, Claims Explorer, Pareo, CAS, and EHUB.

• Served as an SME for disenrollment and escalations, documenting case histories in Salesforce and CI to preserve evidence and support downstream investigations.

Cross-trained across benefits, claims, billing, and appeals to identify trends and flag suspicious activity for further review.

• Supported MA Part C appeals monitoring and managed at-risk case files, producing written summaries and follow-up actions.

Used workforce management and performance metrics to meet quality and productivity goals while handling complex member interactions.

• Processed referrals and authorizations, updated patient records with accurate diagnosis codes, and supported claims submission and reconciliation.

• Ensured documentation integrity to reduce downstream denials, and support audit readiness.

• Coordinated patient appointments and communicated with medical staff for updates.
• Maintained electronic health records for accuracy and confidentiality compliance.
• Scheduled appointments and managed patient records using electronic health record software.
• Maintained knowledge of current insurance requirements for billing purposes.
• Identified trends in denials or rejections of claims and worked to resolve them quickly.
• Assisted in resolving billing disputes between providers and insurance companies and patients.

• Assisted patients with insurance inquiries, providing necessary forms and information.
• Coordinated patient check-in and check-out processes for seamless service delivery.
• Updated and recorded customer or client information to maintain accounts.
• Performed data entry tasks into various computer systems accurately and promptly.
• Processed payments and updated accounts to reflect balance changes.