A’Tara McGhee
Guyton,GA
Summary
Healthcare operations specialist with a background in appeals, grievances, intake, and compliance support across patient access, revenue cycle, and clinical workflows. Reviews documentation, monitors performance indicators, supports audits, and partners across departments to improve service quality, documentation accuracy, and member satisfaction.
Overview
12
12
years of professional experience
Work History
Healthcare Operations Specialist
eviCore by Evernorth
05.2021 - Current
- Managed operational workflows to enhance patient access, streamline revenue cycle activities, support clinical services, and ensure regulatory compliance.
- Monitored departmental performance indicators and developed process improvements that increased operational efficiency and service quality.
- Partnered with leadership teams to implement and refine healthcare policies, quality improvement strategies, and compliance programs, driving organizational alignment.
- Conducted data analysis and reporting to identify trends, operational risks, and improvement opportunities.
- Collaborated with multiple departments to enhance member satisfaction and elevate operational performance.
- Supported staff training initiatives to ensure adherence to healthcare regulations and organizational procedures.
- Assisted with internal audits, process assessments, and corrective action planning.
- Maintained accurate documentation and records management practices in accordance with HIPAA requirements.
- Worked in a fully remote capacity, collaborating with teams across various locations.
Senior Appeal Grievance Coordinator
eviCore by Evernorth
09.2016 - 05.2021
- Conduct comprehensive reviews of member appeals, grievances, complaints, and escalations while ensuring compliance with CMS, Medicare, Medicaid, and organizational requirements.
- Investigate complex cases involving claims processing, authorization determinations, benefit interpretation, and service concerns.
- Analyze medical records, provider documentation, contracts, and supporting evidence to determine appropriate case outcomes.
- Collaborated with medical directors, utilization management teams, providers, and operational leadership to effectively resolve case issues and improve member experiences.
- Identified trends and recurring service concerns through root cause analysis, recommending corrective actions to enhance service delivery.
- Maintained regulatory turnaround standards, ensuring accurate documentation and timely communication with members to uphold compliance.
- Support audit readiness initiatives and maintain compliance with federal, state, and accreditation requirements.
- Consistently exceed productivity, quality, and case-resolution performance metrics.
Non-Clinical Intake Representative
eviCore by Evernorth
02.2015 - 09.2016
- Processed prior authorization intakes for eviCore by Evernorth utilization management cases.
- Reviewed incoming healthcare requests and records to ensure completeness and accuracy for efficient routing.
- Reviewed medical records and referral documents for intake accuracy.
- Maintained confidential electronic case documentation while prioritizing high-volume intake assignments to meet established processing timelines.
- Confirmed member eligibility through employer systems. and benefits using employer systems.
Education
Bachelor of Science - Business Administration
Southern New Hampshire University
Manchester, NH06-2028
Skills
- Appeals resolution
- Regulatory compliance support
- Compliance Readiness
- Risk escalation management
- Documentation review
- Quality Assurance
- Performance Metrics Analysis
- Root-Cause Analysis
- Process Improvement
- Operational Workflow Optimization
- Complaint workflow support
- Issue research
- SME / Peer Guidance
- Effective Stakeholder Communication
- Collaboration skills
- HIPAA / PHI Protection
- Microsoft Office proficiency
Personal Information
Title: Appeals & Grievances Specialist | Healthcare Compliance | Remote Operations
Accomplishments
- Resolved high-volume appeals and grievance cases while maintaining 98% quality review scores.
- Improved turnaround time compliance through workflow optimization and case management enhancements.
- Reduced recurring member complaints by identifying root causes and implementing corrective action recommendations.
- Supported successful regulatory audits with zero major findings.
- Contributed to operational initiatives that improved productivity, customer satisfaction, and compliance outcomes.
Remote Work & Independence
- Problem Solving
- Fully Remote Environment
- Virtual Workforce
- Distributed Teams
- Remote Operations
- Independent Decision-Making
- Self-Directed Professional
- Self-Management
- Autonomous Work Environment
Timeline
Healthcare Operations Specialist
eviCore by Evernorth
05.2021 - Current
Senior Appeal Grievance Coordinator
eviCore by Evernorth
09.2016 - 05.2021
Non-Clinical Intake Representative
eviCore by Evernorth
02.2015 - 09.2016
Bachelor of Science - Business Administration
Southern New Hampshire University