BRENDALYN L. GREEN
Tampa,USA
Summary
Quality assurance specialist with keen eye for detail, ensuring compliance with standards and regulations. Adept at identifying areas for improvement and implementing effective solutions. Strong focus on team collaboration and achieving results, with flexible approach to changing needs. Proven skills in data analysis, process optimization, and report generation. Reliable and adaptable, consistently driving quality and efficiency in every project.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Senior Appeals Quality Auditor
Centene Corporation
01.2022 - Current
- Responsible for auditing providers data loaded into claims processing systems, documenting and reporting audit reports
- Research issues from reviewed claims to determine origins and appropriate resolutions
- Summarizes findings and recommendations in reports for feedback and distributes to management
- Summarizes findings and recommendations in reports for feedback
- Ensuring that appeals are handled accurately, efficiently, and in compliance with relevant regulations and company policies.
- Investigating the root causes of errors or issues and recommending corrective actions.
- Working with other teams, such as claims, customer service, to address quality and compliance issues
Appeals Intake Specialist
Centene Corporation
01.2018 - 01.2022
- Processed incoming members and providers appeals and re-routed grievances
- Processed pharmacy claims correspondence received from healthcare providers, patients, or insurance companies, etc.
- Researched and successfully input accurate data entry and finalized the initial processing
- Check if the appeal is within the timeframe allowed and meets necessary criteria to be reviewed.
- Ask clarifying questions to fully understand the appeal, request additional documents as needed, and ensure all necessary information is captured.
Behavioral Health Intake Rep
Centene Corporation
11.2013 - 01.2018
- Received inbounds calls regarding authorization requests
- Emailed and fax provider updated forms upon request
- Verified procedure and IC9 codes
- Entered data and researched requests
- Crossed trained in medical authorizations
- Identified par and non-par providers
- Reached out to providers to help with sign on questions to portal and keep demographics current
- Work cross functionally with internal departments regarding provider needs, requests and work procedures
- Conduct provider and health plan telephonic education as needed.
Human Resource Specialist
Data Outsource Services
07.2012 - 11.2013
- Filing, interviewing, and selecting new employees
- Administering employee benefits and handling related questions.
- Processing payroll and ensuring employees are paid accurately and on time
- Developing and conducting training programs to improve employee skills and performance.
- Handling employee relations issues and liaising between employees and managers
- Ensuring compliance with labor and employment laws
- Providing guidance and support to employees and managers on HR topics
- Provide information and guidance on leave policies, procedures, and programs
- Make sure that leave programs comply with federal and state laws
- Communicate with employees about their leave needs and responsibilities
- Oversee the return-to-work process for employees returning from leave
Education
Certificate - Human Resource Management
University of Phoenix
01-2025
Diploma - Medical Office Administration
MCED Career College
High School Diploma - Business
King Leon High School
Skills
- Team leadership
- HIPAA regulations knowledge
- Experience with ATS systems
- Compliance auditing
- Claims management
- Insurance eligibility verification
- Employee onboarding
- Healthcare provider relations
- Skilled in resolving conflicts
- Human resource management fundamentals
- Compensation analysis
- Human resource risk assessment
- Human resources management expertise
- Labor law expertise
Certification
Human Resource Management
Timeline
Senior Appeals Quality Auditor
Centene Corporation
01.2022 - Current
Appeals Intake Specialist
Centene Corporation
01.2018 - 01.2022
Behavioral Health Intake Rep
Centene Corporation
11.2013 - 01.2018
Human Resource Specialist
Data Outsource Services
07.2012 - 11.2013
Diploma - Medical Office Administration
MCED Career College
High School Diploma - Business
King Leon High School
Certificate - Human Resource Management
University of Phoenix
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