Burnetta Payne
Brentwood,CA
Summary
Experienced professional with background in analysis and approval of routine and complex claims working with all types of insurance with proven research and problem. Offering 15 years of experience with Grievance and Appeals. Experience with Electronic Health Record and Case Management. Management of Behavioral Health, Medical, or Workers Comp and, LOA claims extensive demonstrated competency in Coding, Medical Terminology, and extensive knowledge with DOFR Program, logical thinking. Managed Care experience in (Medicaid and Medi-Cal), COSMOS, CIWRS or CPW, ICD-9, ICD-10, experience, and coding. Responsible for performing credentialing delegation oversight compliance for Delegated groups for Medicare, HMO or PPO. Experienced in identifying the needs of customers issues and provide solutions. Experienced in Preauthorization, claims verification, Insurance, Medical claims and Utilization. Manages high volume of complex data that requires a high volume of accurate data entries and reconciliation. Extensive Data Entry Performed different tasks to ensure HEDIS data and reports are accurate, including investigation, auditing, and improvement opportunities. Experienced in customer service to all incoming/ outgoing callers and answering their inquiries. Proficient in MS Office including Word, Excel, Power point and Outlook. Available anytime for an interview with 24-hour prior notice and can join immediately.
Professional with strong background in case management, prepared to make significant impact. Proven ability to collaborate with teams and adapt to changing needs. Skilled in client assessment, resource coordination, and crisis intervention. Reliable and results-focused, with commitment to achieving positive outcomes.
Knowledgeable Social Worker with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes. Demonstrated strong communication and problem-solving skills in high-pressure environments. Knowledgeable Social Worker with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes. Demonstrated strong communication and problem-solving skills in high-pressure environments. Knowledgeable Social Worker with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes. Demonstrated strong communication and problem-solving skills in high-pressure environments. Knowledgeable Case Manager with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes. Demonstrated strong communication and problem-solving skills in high-pressure environments. Knowledgeable Case Manager with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes. Demonstrated strong communication and problem-solving skills in high-pressure environments. Knowledgeable Case Manager with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes. Demonstrated strong communication and problem-solving skills in high-pressure environments. Knowledgeable Case Manager with solid history of managing complex caseloads and providing comprehensive support to diverse client populations. Proven ability to assess client needs and develop tailored action plans that drive positive outcomes..
Overview
25
25
years of professional experience
1
1
Certification
Work History
Case Manager
United Behavioral Health
San Ramon, California
04.2024 - 04.2025
- Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
- Advocated for client rights when interacting with external agencies or institutions, ensuring fair treatment at all times.
- Strengthened relationships with community organizations to increase access to supportive resources for clients in need.
Grievance and Appeals Coordinator: (Contract)
Alameda Alliance
Alameda, California
05.2022 - 03.2024
- Coordinate grievance and appeal activities by receiving, handling, and resolving member issues and operational issues with other organizational staff; Perform ongoing data entry.
- Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
- Make decisions within department guidelines and policies.
- Maintain pertinent documents, case files, and correspondence in an organized, confidential, and secure manner.
- Maintain databases for tracking and reporting purposes; and
- Complete other duties and special projects as assigned.
- Acted as a departmental resource on appeals matters.
- Coordinated with senior specialist to compose appeal responses.
- Responded to attorney inquiries and litigation notices.
The Leave and Disability Specialist
University of California
Concord, California
03.2018 - 03.2022
- I was responsible for supporting the Companies leave of absence program administration in North America. serve as the subject matter expert on leave of absence administration, requests, and accommodations under the Family and Medical Leave Act (FMLA), the Americans with Disabilities Act (ADA), state and local leave laws, and short-term or long-term disability plans. Participated as a Case Management Team member (with supervisors and staff from Human Resources, Safety, and Workers' Compensation), provide best-in-class clinical and administrative case management services for
- (1) medically necessary work activity restrictions
- (2) work absences due to serious health conditions requiring use of company's Short-Term Disability program and qualifying for Family and Medical Leave Act (FMLA) leave. Ensure compliance with any Federal, State or company leave policies and requirements.
- Knowledge, Skills, and Abilities:
- Knowledge of the leave requirements and other legal protections afforded by the FMLA, ADA, and other applicable laws.
- Strong project management and organizational skills.
- Exceptional customer service focus, utilizing excellent interpersonal skills for the purpose of communicating and listening, and with an emphasis on tact and diplomacy.
- Excellent organizational skills and attention to detail
- Detail-oriented with strong organizational skills.
- Strong written and verbal communication skills.
- Proficient in Microsoft Office Suite applications - Excel, Word, PowerPoint, Outlook, or the equivalent.
- Collaborated with medical professionals to gather pertinent information for accurate decision-making on disability claims.
- Effectively communicated complex information about disability benefits programs to a diverse clientele, ensuring that all individuals had a clear understanding of their entitlements and available resources.
- Identified opportunities for continuous improvement within the department, implementing changes that enhanced overall service quality and efficacy in assisting disabled individuals.
- Served as a liaison between clients and government agencies to help expedite benefit approvals when necessary, advocating effectively on behalf of those seeking assistance through the disability benefits system.
- Demonstrated strong organizational skills by efficiently managing a high volume of cases concurrently while maintaining meticulous attention to detail and accuracy in documentation processes.
- Educated clients about available resources and support services, empowering them to make informed decisions about their healthcare options.
- Negotiated reasonable accommodations with employers on behalf of disabled employees, promoting workplace inclusivity and equal access opportunities.
- Managed complex cases involving multiple diagnoses or challenging circumstances, demonstrating exceptional problem-solving skills in navigating logistical hurdles.
- Remained up-to-date on industry trends and advancements in disability support services, leveraging this knowledge to better serve claimants and their families.
- Conducted thorough case reviews, maintaining detailed records for each claimant''s application process.
- Developed individualized plans to facilitate successful reintegration into the workforce for disabled individuals.
- Maintained comprehensive knowledge of federal regulations and policies governing disability benefits programs, ensuring compliance at all times.
- Streamlined internal processes to enhance team efficiency and productivity in managing caseloads.
- Evaluated disability claims for eligibility, ensuring accurate and timely processing of applications.
- Led training sessions for new hires on best practices in disability claims management, fostering a collaborative team environment focused on excellent client service outcomes.
- Exceeded performance metrics by consistently meeting or surpassing established goals for completing case evaluations within specified timeframes.
- Assisted clients in understanding their rights and responsibilities under the Social Security Disability program.
- Worked with medical teams, patients and families to implement effective treatment plans.
- Provided crisis intervention services to individuals facing medical, emotional and mental health challenges in hospital setting.
- Collaborated with healthcare providers to drive continuity of care.
- Facilitated family meetings to discuss patient care plans.
- Assessed risk factors of patients and made referrals for further services.
- Assisted patients in accessing housing, financial assistance and other community resources.
- Conducted in-home visits to provide supportive services.
- Maintained detailed records of patient progress, documentation of services and case notes.
- Worked with children and parents to closely monitor and record social, behavioral and academic growth.
- Monitored client vital signs, administered medications, and tracked behaviors to keep healthcare supervisor well-informed.
- Checked medication schedules and patient needs to enforce medication administration standards team-wide.
- Adhered to company requirements for patient interactions and care standards.
- Kept accurate records for client files and handled related paperwork.
- Transported patients via wheelchair to and from rehabilitation and daily activities.
- Cleaned house, ran errands, managed laundry, and completed weekly grocery shopping.
- Provided high level of physical support by lifting, adjusting, and moving clients.
- Prepared nutritious meals to meet individual dietary needs for clients.
- Kept detailed daily logs with care actions, patient behaviors, and incidents.
- Maintained safety with tidy, clean, and hazard-free home environments.
- Improved client satisfaction by efficiently addressing and resolving disability claims inquiries.
- Provided compassionate support to clients during difficult life transitions due to illness or injury, fostering positive relationships with claimants and their families.
- Partnered closely with interdisciplinary teams consisting of doctors, therapists, and social workers to coordinate comprehensive care for disabled clients.
- Provided assistance in daily living activities by dressing, grooming, bathing, and toileting patients.
- Drove clients safely to social activities and appointments.
Compliance Sr. Appeals Case Analyst / Credentialing Specialist
United Healthcare Behavioral
12.2017 - 01.2018
- Primary responsibility to review, evaluate, and corrects Member's grievance letters.
- Proven editing experience with cutting and pasting and correcting written content to customers.
- 100% of the primary function of this role is business writing expertise in a member service
- Grievance and appeal environment all phases of Medicare.
- Participated in the review of member letters to provide recommendations and guidance on strengthening letter content and readability for our written correspondence.
- Process experience in evaluating content and documenting process improvement opportunities to improve the quality of letter content and readability, empathetic responses.
- Participate in managing the organization's complaint and grievance process.
- Accountable for investigation of all issues, including collection and documentation of appropriate data. To have a professional representation in customer service role model in interactions with internal and external customers; patients, families, visitors, hospital/health system personnel, outside vendors, external organizations, and physicians.
- Identify and address specialty, flagged cases and follow appropriate processes for different types of cases Communicate with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation, and enhancement of the member experience.
- Research, resolve and communicate complaints and grievances filed by members and communicate Health Plan's decisions appropriately back to member or their authorized representatives. Provided a variety of routine and specialized departmental administrative support to Medical Staff. Worked independently exercising sound judgement and executed developed administrative skills.
- Responsible for instituting corrective action for non-compliance.
- Responsible for performing credentialing delegation oversight compliance for Delegated groups for Medicare, HMO or PPO.
- Ensured that complaints and grievances are processed in accordance with regulations, Compliance standards and policies and procedures.
- Assessed needs of each client and recommended appropriate services and resources.
- Maintained high level of client confidentiality, following strict guidelines, and recommendations.
- Created treatment or service plan meeting each client's individualized needs.
- Provided crisis intervention and case management services to child, family and legal guardians.
Clinical Senior Appeals Specialist/ Credentialing Specialist
United Behavioral Healthcare
03.2000 - 11.2017
- Analyzed and approval of routine claims.
- Adjudicated customers claim, completed audits, and adjusting claim examiners' settlement limits.
- Processed Urgent Appeals writing letters and notifying facilities of the outcome and advising of further appeal rights.
- Process Non-Coverage Determinations and attaching appropriate state and federal rights.
- Read/ reviewed 15-20 appeals letters on daily basis as per the compliance/regulations.
- Reviewed settled insurance claims to determine that payments and settlements have been.
- Made in accordance with legal compliance and company practices and procedures.
- Reviewed covered losses, establishing proof of loss, over-payments, underpayments, and other irregularities.
- Used some judgment to determine course of action.
- Generated claims to Medicare, Medical and or commercial insurance.
- Generated claims related to inpatient or outpatient mental health services.
- Accurate recordings of charges, payments and adjustments.
- Ensures accurate and timely posting of billing information and posts cash receipts.
- Performs collections follow-up process in accordance with established procedures.
- Manages high volume of complex data that requires a high volume of accurate data entries and reconciliation.
- Authorizations/denials, naming & housing of imaged documents); Documents claim transactions and activities in claim management system notes and establishes claim diaries for ongoing claim management.
- Collaborated with cross-functional teams to gather necessary documentation and evidence to support the appeals process.
- Managed high-stress situations with professionalism, ensuring that appeals were handled promptly and accurately even under tight deadlines or heavy caseloads.
- Achieved successful appeal outcomes by meticulously reviewing and analyzing claim denials, identifying errors, and presenting persuasive arguments.
Education
Bachelor of Arts Degree - Business, Medical Management, Social Services
Northwestern University
Evanston, Illinois01.1979
Skills
- Health care management
- HEDIS measures expertise
- Customer assistance
- Grievance management
- Customer support resolution
- Strong sense of urgency
- Patient care management
- Microsoft Excel proficiency
- Regulatory compliance enforcement
- Effective utilization strategies
- Professional certification
- Healthcare billing
- Insurance expertise
- Medicare administration
- Healthcare expertise
- Claims management
- Employee performance evaluation
- Customer loyalty management
- Document management
- Business planning
- Comprehensive case management
- Effective time management
- Comprehensive case documentation
- Effective active listening
- Organizational skills
- Documentation proficiency
- Network development
- Effective decision-making
- Effective conflict resolution
Accomplishments
- Resolved product issue through consumer testing.
- Supervised team of 21 staff members.
- Used Microsoft Excel to develop inventory tracking spreadsheets.
Certification
- [Coding, Unitedhealthcare - 6 months
Languages
English
Professional Working
Timeline
Case Manager
United Behavioral Health
04.2024 - 04.2025
Grievance and Appeals Coordinator: (Contract)
Alameda Alliance
05.2022 - 03.2024
The Leave and Disability Specialist
University of California
03.2018 - 03.2022
Compliance Sr. Appeals Case Analyst / Credentialing Specialist
United Healthcare Behavioral
12.2017 - 01.2018
Clinical Senior Appeals Specialist/ Credentialing Specialist
United Behavioral Healthcare
03.2000 - 11.2017
Bachelor of Arts Degree - Business, Medical Management, Social Services
Northwestern University
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