Bianca J. Talley
York,PA
Summary
Experienced Claims Processor with over 10 years of experience in the insurance industry. Skilled in effectively communicating with clients and colleagues to ensure accurate and efficient processing of claims. A natural leader who is attentive to details, ensuring that all claims are processed with exceptional quality and competence. Seeking a position where I can utilize my education, experience, and skills to meet and exceed set standards and goals.
Overview
11
11
years of professional experience
Work History
Medicaid Reviewer
Empower AI
02.2024 - Current
- Knowledge of, and the ability to correctly identify, insurance coverage guidelines.
- Familiarity with CPT codes, ICD-10-CM codes, and HCPCS codes.
- Knowledge of and ability to use Microsoft Word, Excel and Internet applications.
- Working knowledge of medical terminology and experience in the review of Medicaid electronic claims are required as well as experience related to specific workload of the individual task order, which may be further defined in the Task Order Statement of Work.
- Communicates internally with all levels of PERM(Payment Error Rate Measurement).
- Complies with departmental policies and procedures.
- Complies with Statement of Work (SOW) guidelines and CMS directives and regulations pertaining to improper payments in the Medicaid and CHIP programs.
- Attends departmental and required education and training programs.
- Performs other projects or duties as assigned by the Data Processing Review Manager or Lead Medicaid Reviewer.
Sr. Claims Processor (Medicare Rework)
Cigna
04.2022 - 10.2023
- Processed UB-04 and HCFA1500 claims.
- Examined and processed electronic claims, repriced and reprocessed claims that previously processed and paid incorrectly according to the contract, reprocessed claims that were denied for timely filing.
- Determined whether to return, pend, deny or pay claims within the policies.
- Knowledgeable of processing Inpatient, Outpatient and Home Health claims.
- Received Delta and Transfer files from the state with Authorizations and Updates to add to claims for processing and payment.
- Worked Fallout Reports from Monthly Conversion Files, adding RUGS, Applied Income and Revenue Codes to authorizations in QNXT Database.
- Created authorizations members in Nursing Facilities for payment of their claims.
- Maintained database records for Medicare membership, assisted with Medicare eligibility and enrollment questions.
- Updated Medicare Coordination of Benefits (COB).
- Processed and monitored the daily (TRR) Transaction Reply Report that CMS provides to ensure both systems are in sync (QNXT and MARX).
- Resolved Prescription Drug Event (PDE) eligibility data discrepancies to ensure accurate Part D payments.
- Processed Best Available Evidence (BAE) request for Low Income Subsidy (LIS) updates to establish the appropriate cost sharing for low-income beneficiaries.
- Worked Weekly Reports created by IT which compared QNXT to the TRR and the full enrollment file to find members with various discrepancies such as LIS mismatches and contract mismatches, etc.
- Collaborate with cross-functional teams to develop and implement process improvements for claims processing, resulting in increased efficiency and accuracy.
- Identify trends and patterns in claims processing data to improve efficiency and accuracy and recommend process improvements to management.
- Implement new software tools or technologies to streamline claims processing and improve accuracy.
Claims Processor (Medicaid Research)
Cigna
09.2016 - 04.2022
- Identify and resolve any issues or discrepancies in Medicaid claims research to ensure accurate and timely processing.
- Conduct detailed research and analysis on Medicaid claims to identify any potential errors or discrepancies.
- Implement process improvements to streamline Medicaid claims research and increase efficiency.
- Collaborate with cross-functional teams to develop and implement strategies for improving the accuracy and efficiency of Medicaid claims processing.
- Collaborate with other departments to gather relevant data and information for Medicaid claims research.
- Train and mentor junior claims processors on Medicaid research best practices to ensure consistent and accurate processing.
- Develop and deliver training programs to educate new hires on Medicaid claims research and processing procedures.
Eligibility Analyst Associate
Cigna
Baltimore
01.2015 - 09.2016
- Analyze and interpret data to identify trends and patterns in eligibility data.
- Identify and implement process improvements to increase efficiency and accuracy in eligibility data management.
- Develop and implement strategies to improve the accuracy and efficiency of eligibility data analysis.
- Collaborate with cross-functional teams to develop and implement strategies for improving eligibility data accuracy and efficiency.
- Collaborate with cross-functional teams to gather and analyze eligibility data from various sources.
- Utilize predictive analytics to forecast eligibility data trends and make proactive recommendations for process improvements.
- Assist in the development and maintenance of data governance policies and procedures.
Education
High School Diploma -
Southwestern Senior High School
Baltimore, MDSkills
- Teamwork and Collaboration
- Critical Thinking and Problem Solving
- Professionalism and Strong Work Ethics
- Oral and Written Communication Skills
- Proficient with Excel
- Proficient with Outlook
- Proficient with Microsoft Word
Timeline
Medicaid Reviewer
Empower AI
02.2024 - Current
Sr. Claims Processor (Medicare Rework)
Cigna
04.2022 - 10.2023
Claims Processor (Medicaid Research)
Cigna
09.2016 - 04.2022
Eligibility Analyst Associate
Cigna
01.2015 - 09.2016
High School Diploma -
Southwestern Senior High School