Roxanne Moore
Charlotte,NC
Summary
Results-oriented achiever with proven ability to exceed targets and drive success in fast-paced environments. Combines strategic thinking with hands-on experience to deliver impactful solutions and enhance organizational performance.
Overview
9
9
years of professional experience
Work History
Appeals and Grievances Specialist
HEALTHFIRST CORPORATION
09.2023 - Current
- Receives documents, investigates, refers and coordinates grievances and appeals
- Maintains database for completing appeal reports required by agencies and the organization
- Research and analyze Medicare claims and related material including customer history
- Compose formal letters of redeterminations and other issues
- Appropriately use the system for tracking/trending purposes
- Keep abreast of all changes/updates regarding Medicare policy and departmental guidelines
- Reviewed and reprocessed, when necessary, Medicare B claims to utilize a thorough knowledge of ICD9, CPT, and HCPCS codes to ensure a 99% accuracy billing rate
- Provided prompt customer service to members, providers, billing departments, and other insurance companies regarding claims
- Experience with Salesforce, PEGA, MACESS, TrueCare, MHS and OnBase
- Proficient in Microsoft Office Suite applications including Excel, Word and Outlook.
Credentialing Project Specialist
HEALTHFIRST CORPORATION
03.2016 - 09.2023
- Credentialing and Re-Credentialing Physicians, Nurses, and Mental Health Providers to become in-network participating providers with Healthfirst
- Works with internal and external contacts to ensure that applications for initial credentialing and re-credentialing are processed promptly
- Performs primary source verifications using license verification websites
- Performs NPDB reporting verifications
- Daily data entry using MACESS, MHS, and Cactus Software Systems
- Compliance with NCQA compliance standards
- Daily interactions with the leadership team and director
- Maintains CAQH, NPPES, and Cactus databases for providers
- Electronic filing, faxing, emailing, and answering high-volume telephone systems
- Maintains knowledge of credentialing standards policies and procedures
- Maintain documentation and reports using MS Word, Excel, and PowerPoint
- Exceptional attention to detail
Education
Bachelor's - Psychology
UNIVERSITY OF PHOENIX
01.2019
Skills
- Organized
- Detail Oriented
- Computer Literacy
- Excellent Customer Service
- Time Management
Timeline
Appeals and Grievances Specialist
HEALTHFIRST CORPORATION
09.2023 - Current
Credentialing Project Specialist
HEALTHFIRST CORPORATION
03.2016 - 09.2023
Bachelor's - Psychology
UNIVERSITY OF PHOENIX
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