Brandi M. Caudle
Newport News,VA
Summary
Healthcare analyst with expertise in healthcare administration, customer service, claims analysis, reimbursement, and certification. Proven track record in optimizing processes and managing projects to enhance operational efficiency. Strong data analysis skills contribute to streamlined workflows and improved productivity. Effective communicator and problem-solver, fostering team collaboration to achieve organizational objectives.
Overview
11
11
years of professional experience
Work History
Reimbursement Representative III
Department of Behavioral Health & Developmental Services
, Virginia
12.2022 - Current
- Maximizing revenue generated from charges and costs for clients receiving inpatient services for facilities.
- Collecting and analyzing financial information to determine and evaluate a client’s ability to pay, in accordance with the Virginia State Code.
- Assisting clients, responsible parties, and facility staff on reimbursement matters and managing past due accounts to include legal actions and debt set off
- Actively engaging in activities to reduce aging inventory
- Utilized document management system to organize company files, keeping up-to-date and easily accessible data.
- Identified areas for improvement, narrowing focus for decision-makers in making necessary changes.
- Facilitated training sessions for new employees on company policies and procedures.
Tier II Claims Analyst
Anthem
Virginia Beach, VA
07.2020 - 12.2022
- Application of policy and provider contract provisions to determine if a claim is payable.
- If additional information is needed, or if a claim should be denied,
- Determine the status of medical claims through research, reviewing charges, and the use of payment or denial codes within established guidelines and standards.
- Maintenance of records, files, and documentation.
- Meet the standards of department production and quality standards.
- Ensured compliance with federal and state regulations governing insurance industry operations.
- Participated in claims audit processes to ensure compliance with internal and external standards.
- Conducted investigations to gather evidence in support of claims resolution.
- Analyzed claims data to determine coverage and liability, ensuring accurate decision-making.
- Assisted in the development and implementation of claims procedures to improve efficiency.
Tier III Claims Processor
Kelly Services; Anthem
Virginia Beach, VA
01.2020 - 04.2020
- Keying, processing and/or adjusting health claims in accordance with claims policies and procedures
- Worked without significant guidance w/ basic understanding of multiple products (HMO, PPO, COB, etc.)
- Maintaining an understanding of the application of benefit contracts, pricing, processing, policies, procedures, government regulations, coordination of benefits, and healthcare terminology.
- Reviews, analyzes, and processes claims and policies related to events to determine the extent of the company's liability and entitlement.
- Adjusts voids and reopens claims online within guidelines to ensure proper adjudication.
Provider Certification Analyst II
WPS
Hampton, VA
08.2018 - 10.2019
- Assisted in the maintenance of TRICARE Provider File online system, including determination of provider certification, eligibility, and network status, and ensure accuracy for TRICARE National provider file shared by all TRICARE offices
- Obtained and tracked provider certification data to ensure the application is approved and/or denied according to TRICARE guidelines.
- Initiate telephone calls to providers to obtain additional information to resolve certification issues.
- Validate, through research, that all provider certification data entered into the online system is accurate for claims processing.
- Identify claims processed erroneously, and initiate appropriate reprocessing steps.ps
- Verified eligibility of providers including institutional providers and mental health specialties, according to TRICARE guidelines using appropriate regulatory boards
- Collaborated with cross-functional teams on projects related to analytics initiatives.
- Evaluated needs of departments and delegated tasks to optimize overall production.
Member Service Representative II/ Prior Authorizations Specialist
Broadpath
WAH
01.2018 - 08.2018
- Maintained accurate records, files, and documentation to support operational needs.
- Coordinated service distribution via emails and faxes to providers.
- Entered new authorizations and modifications into systems promptly.
- Executed tasks to promote participant compliance, including appointment verification and lab result collection.
- Screened for eligibility and benefits to ensure proper access.
- Prioritized member assessments and referred cases to appropriate teams based on established workflows.
- Collaborated with community-based organizations to enhance service coordination.
Customer Service Representative
Alorica PayFlex
WAH (Remote)
09.2017 - 03.2018
- Ensured high-quality client support through exceptional customer service delivery.
- Responded to inquiries on Flexible Spending Arrangements (FSA) and healthcare eligibility.
- Researched customer inquiries using multiple web-based systems to provide effective solutions.
- Coordinated with internal teams to guarantee timely delivery of tailored solutions.
Medical Customer Service Representative
Health Net Federal Services
Hampton, VA
06.2015 - 10.2017
- Efficiently scheduled and canceled patient appointments through effective call handling.
- Reviewed computerized appointment templates to evaluate availability of appointment types and slots.
- Analyzed and resolved scheduling issues, improving overall operational flow.
- Documented transactions accurately in medical management systems to ensure compliance.
- Drafted clear and professional responses to inquiries, enhancing communication quality.
- Contacted medical provider offices to collect notes, transmitting information to Department of Veterans Affairs.
Customer Service Representative
Faneuil-WAHBE
Hampton, VA
10.2014 - 06.2015
- Processed Healthcare enrollment & payments of premiums
- Provided floor support & Outbound Survey Training
Education
Bachelors - Healthcare Management
University of Phoenix
Phoenix, AZ10-2025
H.S. Diploma -
Hertford County High School
Ahoskie, NC05-2000
Skills
- Healthcare administration
- Customer service and support
- Claims analysis and reimbursement
- Provider certification management
- Financial analysis
- Team leadership and collaboration
- Goal orientation
- Process improvement
- Revenue generation
- Self-motivation
- Problem-solving
References
References available upon request.
Timeline
Reimbursement Representative III
Department of Behavioral Health & Developmental Services
12.2022 - Current
Tier II Claims Analyst
Anthem
07.2020 - 12.2022
Tier III Claims Processor
Kelly Services; Anthem
01.2020 - 04.2020
Provider Certification Analyst II
WPS
08.2018 - 10.2019
Member Service Representative II/ Prior Authorizations Specialist
Broadpath
01.2018 - 08.2018
Customer Service Representative
Alorica PayFlex
09.2017 - 03.2018
Medical Customer Service Representative
Health Net Federal Services
06.2015 - 10.2017
Customer Service Representative
Faneuil-WAHBE
10.2014 - 06.2015
Bachelors - Healthcare Management
University of Phoenix
H.S. Diploma -
Hertford County High School
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