Summary
Overview
Work History
Education
Skills
Timeline
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Caprice Carter

Lithia Springs,GA

Summary

Experienced healthcare analyst and coordinator with 10+ years of proven critical thinking, communication, and analytical thinking skills within the healthcare industry. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.

Overview

12
12
years of professional experience

Work History

Claims Examiner

Emblemhealth
06.2023 - Current
  • Conducted comprehensive claims reviews to identify discrepancies and inconsistencies in documentation
  • Analyzed data and records to determine the accuracy of insurance claims, ensuring compliance with company policies and industry regulations
  • Generated detailed reports and summaries of claims analysis findings for management and stakeholders
  • Implemented process improvements and provided recommendations for enhancing the claims review workflow, resulting in reduced errors and quicker claims processing
  • Proactively guide the selection of appropriate Configuration Templates and spearhead innovative designs to address the ever-evolving landscape of pricing requirements
  • Proficiently navigates the complexities of provider contracts and pricing documentation to meticulously complete configuration design templates
  • Skillfully create standard NetworX templates within both Facets and traditional paper formats, offering valuable guidance to Config Analysts tackling novel configurations
  • Improved overall efficiency within the department by streamlining processes and eliminating redundancies where possible.
  • Paid or denied medical claims based upon established claims processing criteria.

Authorization Coordinator

EmblemHealth
07.2020 - 06.2023
  • Provide timely completion of provider inquiries and request for the hospital, office, ambulance, skilled nursing facility and rehab authorizations
  • This includes auto approving authorizations in collaboration with the nurse team
  • Review medical records to determine whether they contain sufficient information to support a diagnosis or treatment plan
  • Ensured regulatory compliance by closely monitoring applicable laws and regulations within the industry sector throughout each stage of the project life cycle.
  • Coordinated with cross-functional teams to resolve project issues and mitigate risks.
  • Assisted in the successful completion of projects by coordinating tasks, monitoring progress, and maintaining documentation.
  • Maintained database and spreadsheets with accurate inventory and status.
  • Developed comprehensive training materials for new Authorization Coordinators, contributing to their successful onboarding process.

Senior Service Agent

Healthfirst
04.2018 - 07.2020
  • Recorded details of customer interactions, inquiries, complaints, and comments
  • Checked and ensured appropriate changes were made to resolve customer problems
  • Led, guided, trained, and evaluated staff performance
  • Responded to and resolved complex patient questions and issues
  • Monitored daily and weekly pending reports for claims, appeals, and escalations
  • Reviewed, submitted, and escalated appeals and grievance requests in a timely manner.

Service Agent

Healthfirst
05.2013 - 03.2018
  • Navigated through automated information systems to analyze the caller's situation
  • Interacted by phone with providers and members to provide information in response to inquiries, concerns, and questions about insurance coverage and products Healthfirst offers while accurately documenting in CRM
  • Performed research on billing inquiries and claims to provide payments and refunds
  • Outreach to enrolled and terminated members to retain account membership by scheduling at home or facility appointments
  • Transferred calls from members and providers to the appropriate department.

Office Administrative Assistant

Healthfirst
08.2012 - 03.2013
  • Handled sensitive patient information with utmost discretion, adhering to HIPAA guidelines at all times.
  • Assisted in the preparation of presentations, contributing to successful meetings with key stakeholders.
  • Managed office supplies inventory, anticipating needs and placing orders proactively to avoid shortages.
  • Contributed to the development of company policies and procedures through active participation in internal discussions and workshops.
  • Collaborated with various departments on special projects, demonstrating adaptability and strong teamwork skills.
  • Improved document organization system by implementing digital filing solutions that simplified retrieval processes for team members.

Education

B.S. Healthcare Management -

Ashworth College
Norcross, GA
10.2020

A.A. Criminal Justice -

Ashworth College
Norcross, GA
03.2020

Honors Certificate in Paralegal Studies -

Ashworth College
Norcross, GA
01.2020

Skills

  • Report Generation
  • Process Improvement
  • Provider Contract Navigation
  • NetworX Template Creation
  • Medical Records Review
  • ICD-9
  • CPT Codes
  • Insurance Information Entry
  • Staff Training and Evaluation
  • Patient Issue Resolution
  • Claims and Appeals Management
  • Automated Information System Navigation
  • Provider and Member Interaction
  • Research and Analysis
  • Microsoft Office
  • Excel
  • MHS Oncontact
  • Salesforce
  • CCMS
  • Epaces
  • Macess
  • EDS CMSgov
  • Biztalk
  • Trucare
  • Rightfax
  • Claims Authorizations
  • Billing
  • Auditing
  • Medicare
  • Medicaid
  • Child Health Plus
  • Managed Long-Term Care
  • Essential Plan
  • HFIC Qualified Health Plan
  • EMR
  • Accounts Receivable
  • HIPPA
  • Patient Flow Management
  • Medical Terminology
  • CRMSkills
  • Intergy
  • Citrix
  • HER File Tagging Tool
  • Clinical Care Advance
  • Cmore
  • Factes
  • Zelis
  • HCP
  • Webstrat
  • Evicore
  • Healthcare Regulations
  • Medical Coding
  • Analytical Thinking
  • Rehab Authorizations
  • Claims Adjustment
  • Customer Service and Support
  • Records Review
  • Denied Claims Identification
  • Negotiation and Mediation
  • Policy Analysis
  • Payment Processing
  • Claims Evaluation
  • Claim Form Analysis
  • Claims Review
  • Quality Assurance Practices
  • HIPAA Compliance Awareness
  • Project Coordination

Timeline

Claims Examiner

Emblemhealth
06.2023 - Current

Authorization Coordinator

EmblemHealth
07.2020 - 06.2023

Senior Service Agent

Healthfirst
04.2018 - 07.2020

Service Agent

Healthfirst
05.2013 - 03.2018

Office Administrative Assistant

Healthfirst
08.2012 - 03.2013

B.S. Healthcare Management -

Ashworth College

A.A. Criminal Justice -

Ashworth College

Honors Certificate in Paralegal Studies -

Ashworth College

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Caprice Carter