Brittany Bowens
Baton Rouge,LA
Summary
Exercised strong investigative skills to gather and analyze evidence, ensuring thorough risk assessment.
Professional with strong background in investigative work, adept at gathering and analyzing information to uncover key insights. Known for collaborative teamwork and reliability, consistently adapting to evolving requirements to achieve desired outcomes. Skilled in critical thinking, problem-solving, and effective communication, ensuring thorough and accurate investigations.
Overview
12
12
years of professional experience
Work History
Investigator I
Elevance Health
Baton Rouge, LA
12.2023 - Current
- Reviews claims data by analyzing medical records and billing patterns. Conducts interviews with providers, patients, and witnesses to gather relevant information. Assists in collecting necessary documentation for comprehensive case assessment.
- Maintains accurate and detailed case information in tracking systems, preparing comprehensive investigative and audit reports summarizing findings and recommendations.
- Works closely with internal teams (compliance, legal, audit, IT) and external entities such as law enforcement, regulatory agencies, and attorneys.
- Initiates proactive data mining to detect aberrant billing practices and identify fraud, waste, and abuse trends.
- Assists in the recovery of funds lost due to fraudulent activities.
- Ability to analyze data for irregularities, identify patterns, and draw conclusions based on evidence
- Excellent verbal and written communication skills to effectively interact with various stakeholders, prepare reports, and present findings
Appeals and Grievances Coordinator
AmeriHealth Caritas
Baton Rouge, LA
04.2021 - 04.2023
- Researched and investigated member and/or provider appeals and grievance requests, included review of UM/claim denial reasons, contract/regulatory rules, benefits and documentation received on appeal/grievance
- Compiled comprehensive case files, including all denial information and medical records received during the appeal process.
- Drafted, refined, and delivered comprehensive case summaries as required by procedural guidelines for adverse determinations.
- Managed the organization and delivery of case files to various teams, ensuring timely access for legal and appeal processes.
- Evaluated member appeals and grievances, coordinating resolutions in strict alignment with established regulatory policies and procedures.
- Facilitated management of appeals system by guaranteeing meticulous documentation of appeals and grievances, including all pertinent communications.
- Performed detailed evaluations to maintain specified quality and compliance standards set by governing bodies.
- Developed detailed decision letters that specified appeal and grievance contexts, rationales for decisions made, and pathways for future actions.
- Coordinated communication strategies to collect relevant data for effective resolution of appeals and grievances.
Utilization Management Technician
AmeriHealth Caritas
Baton Rouge, LA
07.2019 - 04.2021
- Reviewed and analyzed clinical service requests to align with evidence-based clinical guidelines, promoting optimal patient care.
- Analyzed treatment requests to establish appropriate benefits and eligibility requirements for procedures.
- Analyzed and evaluated prior authorization requests to determine eligibility for a range of behavioral health services.
- Managed request processing to adhere to specified deadlines and enhance workflow.
- Evaluated and directed appropriate prior authorization requests to medical directors and UM reviewers for timely decision-making.
- Engaged with members and providers to gather necessary information while maintaining efficiency and consistency in outreach.
- Coordinated efforts with multidisciplinary teams to optimize care delivery and patient outcomes.
- Monitored compliance with UM policies and procedures, ensuring consistent application.
Utilization Management Technician
Mindlance Staffing
Baton Rouge, LA
07.2018 - 12.2018
- Analyzed clinical service requests from members or providers against evidence based clinical guidelines
- Identified appropriate benefits and eligibility for requested treatments and/or procedures
- Conducted prior authorization reviews to determine eligibility of behavioral health services
- Processed requests within required timelines
- Referred appropriate prior authorization requests to Medical Directors and UM Reviewers
- Requested additional information from members or providers in consistent and efficient manner
- Collaborated with multidisciplinary teams to promote coordination of care
Medicaid Eligibility Coordinator
University of New Orleans
Baton Rouge, LA
11.2016 - 05.2017
- Facilitated timely processing of Medicaid applications and periodic renewals to support client access to healthcare services.
- Investigated and rectified discrepancies in application management, ensuring smooth processing of applications and renewals.
- Conducted thorough reviews of data systems to secure required information and verification essential for eligibility assessment.
- Monitored and enforced compliance standards to facilitate on-time certification completion.
- Analyzed and recorded eligibility findings in compliance with Medicaid requirements, ensuring accuracy in decision-making processes.
- Streamlined preparation of eligibility decision notices through precise data entry into Medicaid application systems.
- Reviewed and integrated new Medicaid policy changes and updates to ensure adherence to established procedures.
Long-Term Care Case Manager
Xerox, ACS
Baton Rouge, LA
10.2014 - 05.2016
- Facilitated long-term care program selection for Medicaid-eligible elderly and disabled applicants.
- Completed needs-based assessment using the Minimum Data Set-Home Care (MDS- HC) assessment tool which measured applicants' ability to complete their activities of daily living
- Developed and implemented comprehensive person-centered care plans utilizing assessment data and community resources.
- Utilized Electronic Medicaid Eligibility Verification System and appropriate databases.
- Systematically organized and updated detailed records of patient progress, service documentation, and case notes for effective case management.
- Developed and implemented care plans for individuals with complex health needs, ensuring adherence to state regulations.
- Evaluated patient eligibility for long-term care services to ensure access to essential resources and support.
- Collaborated with multidisciplinary teams to develop individualized treatment strategies and improve patient outcomes.
- Educated families on available services, enhancing understanding of care options and support systems.
- Streamlined documentation processes using electronic health record systems to improve data accuracy and accessibility.
- Led quality improvement initiatives aimed at optimizing service delivery and enhancing client satisfaction levels.
Education
Bachelor of Science - Criminal Justice
Southern University At New Orleans
New Orleans, LA05-2008
Skills
Legal compliance
Policy interpretation
Claim analysis
Risk assessment
Data analysis
Risk analysis
Report preparation
Claims resolution
Claims trend analysis
Timeline
Investigator I
Elevance Health
12.2023 - Current
Appeals and Grievances Coordinator
AmeriHealth Caritas
04.2021 - 04.2023
Utilization Management Technician
AmeriHealth Caritas
07.2019 - 04.2021
Utilization Management Technician
Mindlance Staffing
07.2018 - 12.2018
Medicaid Eligibility Coordinator
University of New Orleans
11.2016 - 05.2017
Long-Term Care Case Manager
Xerox, ACS
10.2014 - 05.2016
Bachelor of Science - Criminal Justice
Southern University At New Orleans