CASSANDRA TAYLOR
San Antonio,TX
Summary
Senior healthcare claims professional with over 6 years of expertise in medical claims adjudication and payer operations. Achieved 98% quality scores while managing complex claims and Cigna repricing tasks. Strong analytical skills utilized for interpreting policy language and determining coverage. Proven ability to enhance efficiency and accuracy in claims processing and communicate resolutions effectively to stakeholders.
Overview
17
17
years of professional experience
Work History
Senior Claims Analyst
MedCost
Winston-Salem, NC
08.2023 - Current
- Chosen as one of two analysts for Cigna repricing initiatives, contributing to strategic decision-making.
- Reviewed and repriced complex medical claims according to payer contracts.
- Resolved complex claim issues through detailed evidence examination and legal analysis, enhancing claims accuracy.
- Provided expertise in pricing escalations and conducted quality assurance reviews.
- Analyzed claim pattern trends, identifying potential litigation risks and financial losses to inform proactive measures.
- Maintained 98% quality score over three consecutive years.
- Utilized claims processing software to ensure accurate claim file updates and maintenance.
- Participated in training sessions to improve knowledge of insurance products.
Senior Claims Analyst
Triada
Houston, TX
08.2022 - 06.2023
- Reviewed and evaluated customer claims for coverage under policy provisions or applicable laws.
- Evaluated coverage determinations and medical claims for payment eligibility.
- Investigated questionable claims, resolving discrepancies through thorough documentation analysis.
- Formulated strategies that minimized claim costs while ensuring adherence to service quality standards.
- Assessed daily processing reports to ensure accuracy and timely submissions.
- Partnered with cross-functional teams to enhance claims processing workflows for improved efficiency.
- Guided junior analysts on contract interpretation and related matters to improve team expertise and accuracy.
Medical Claims Examiner
Sutherland Global Services
Houston, TX
08.2018 - 05.2020
- Processed high volumes of medical claims, achieving over 95% quality ratings.
- Applied hold, pay, or deny codes based on claims processing criteria to ensure accurate claim outcomes.
- Submitted appeals to payers for denied or underpaid claims, enhancing recovery rates and facilitating timely resolutions.
- Communicated with healthcare providers regarding claim statuses and resolution issues.
- Conducted audits on claims to ensure compliance with company policies and regulations.
- Validated inclusion of all necessary documentation with each claim submission.
- Maintained strict confidentiality of patient information to ensure HIPAA compliance.
- Completed special projects while meeting production standards to support operational goals.
M&R; Benefit Advocate
United Healthcare
San Antonio, TX
03.2016 - 07.2017
- Guided members in navigating health benefits and coverage options to enhance understanding.
- Informed clients on claims processes and addressed inquiries, improving client satisfaction.
- Communicated effectively via email, phone and face-to-face with plan participants to resolve issues pertaining to health and welfare benefits.
- Streamlined benefits processing for enrollments, terminations, and claims to ensure timely service.
- Maintained accurate records of member interactions and documentation.
- Facilitated training sessions for new team members on policies and procedures.
Team Leader
H4 Engineering
09.2014 - 10.2015
Paid Professional Fundraiser
Statewide Appeal
11.2012 - 09.2014
Production Technician
Frozen Beverage Dispensers
07.2012 - 10.2012
Production Technician
Trane Heating & Cooling
11.2010 - 03.2012
Customer Service Representative
Transcom USA
09.2009 - 10.2010
Education
High School Diploma -
Luverne High School
Luverne05-2004
Skills
- Medical Claims Adjudication, Claims Analysis, Coverage Determination, Claims Repricing, Benefit Coordination, HIPAA Compliance, Policy Interpretation, Adjudication Systems, Data Analysis, Microsoft Excel, Healthcare Operations, Cross-functional Collaboration
Timeline
Senior Claims Analyst
MedCost
08.2023 - Current
Senior Claims Analyst
Triada
08.2022 - 06.2023
Medical Claims Examiner
Sutherland Global Services
08.2018 - 05.2020
M&R; Benefit Advocate
United Healthcare
03.2016 - 07.2017
Team Leader
H4 Engineering
09.2014 - 10.2015
Paid Professional Fundraiser
Statewide Appeal
11.2012 - 09.2014
Production Technician
Frozen Beverage Dispensers
07.2012 - 10.2012
Production Technician
Trane Heating & Cooling
11.2010 - 03.2012
Customer Service Representative
Transcom USA
09.2009 - 10.2010
High School Diploma -
Luverne High School