Chantelle Lewis
Riverview
Summary
Detail-oriented and driven healthcare professional with 15+ years of progressive experience in medical documentation, credentialing, provider enrollment, grievance and appeals resolution, benefit configuration, and complex claims management. Adept at coordinating credentialing processes, ensuring compliance with CMS, Medicare, Medicaid, and HIPAA regulations, and navigating payer and enrollment systems including QNXT, Facets, PECOS, and PBM platforms. Proven track record of leading credentialing and appeals teams, managing high-volume grievance and appeals cases under the No Surprises Act, and leveraging platforms such as Salesforce, Verifiable, Zendesk, and MD-Staff to streamline workflows. Recognized for strong analytical abilities, meticulous attention to detail, and a commitment to organizational integrity, compliance, and provider satisfaction.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Appeals Analyst
MetLife
06.2022 - Current
- Review, research, and resolve provider and member appeals in compliance with regulatory guidelines and internal policies.
- Analyze medical and administrative documentation to validate appeal requests and ensure accurate determinations.
- Apply federal, state, and organizational standards in appeal determinations; draft clear, professional resolution letters.
- Collaborate with cross-functional teams to collect supporting documentation and meet strict turnaround times with high accuracy.
- Provide guidance to team members on complex appeal issues and trends.
Business Configuration Analyst II
Centene
12.2020 - 05.2022
- Designed and implemented benefit setups and hierarchy within PBM systems to support accurate adjudication.
- Executed quality reviews and end-to-end testing for benefit setup accuracy prior to implementation.
- Partnered with compliance to perform post-go-live audits; resolved escalations and provided leadership on configuration inquiries.
Grievance & Appeals Specialist
Centene
11.2017 - 12.2020
- Investigated and resolved complex member and provider grievances and appeals in alignment with CMS, state, and federal regulations.
- Reviewed claims data, EOBs, medical records, and supporting documentation to ensure accurate determinations and timely resolution.
- Prepared and issued clear decision letters; coordinated with clinical reviewers, compliance, and legal on escalated cases.
- Monitored case trends, identified root causes, and recommended process improvements to enhance accuracy and turnaround times.
- Provided guidance and training to team members on grievance and appeals procedures and documentation best practices.
Integrated Specialist
CarePlus Health Plan
02.2013 - 11.2017
- Researched claims for accuracy, processed adjustments, and managed provider inquiries and appeals cases.
- Retrieved and analyzed medical records; applied ICD-9, ICD-10, and CPT codes to ensure proper billing and payment accuracy.
Claims Analyst III
Amerigroup Corporation
Tampa
08.2007 - 01.2013
- Processed advanced-level Medicaid claim transactions in compliance with contract terms and HIPAA standards.
- Prepared production reports and partnered cross-functionally to resolve complex claim issues.
Claims Benefit Specialist
Aetna Healthcare
Tampa
01.2007 - 08.2007
- Reviewed and approved complex claims not auto-adjudicated; verified eligibility and applied medical necessity guidelines.
- Escalated high-level claims to senior specialists to ensure timely resolution and customer satisfaction.
Consumer Banker - CSR
Bank of America
Tampa
02.2004 - 01.2006
- Assisted customers with account inquiries and transactions; investigated unauthorized debit card transactions.
- Processed credit card payments and check claims while maintaining service quality metrics.
Medical Service Representative / Claims Processor
Oxford Health Plans
Tampa
08.2002 - 01.2004
- Responded to provider and member inquiries on claims and authorizations; supported appeals and grievance case resolutions.
- Processed facility and physician claims using CPT, HCPCS, DRG, and ICD-9 coding standards.
Education
High School Diploma -
Wharton High School
Tampa, FL05-1999
Some College (No Degree) - Health Information Technology
Hillsborough Community College
Tampa, FLSkills
- Grievances & Appeals (NSA Compliance)
- CMS Reporting & Independent Dispute Resolution
- Credentialing & Re-Credentialing (NCQA/CAQH Standards)
- Provider Enrollment & Primary Source Verification
- QNXT
- Facets
- Xcelys
- MD Staff
- Verifiable
- Salesforce
- Zendesk
- PECOS
- CAQH
- Availity
- Trizetto
- Brightree
- Smart Docs
- Rivet
- Spot
- Leadership & Staff Training
- Provider Data Integrity
- Electronic Health Records (EHR: NextGen, Epic)
- Medical Documentation & Claims Resubmission
- HIPAA Compliance
- Audit Support
- Strong Understanding of Medical Coding, Billing & Insurance Procedures
- Excellent Problem-Solving & Analytical Skills for Investigating Claim Issues
Certification
- HIPAA Privacy & Security Certified
- CPR & First Aid Certified
- CMS No Surprises Act & IDR Training (2023)
Timeline
Appeals Analyst
MetLife
06.2022 - Current
Business Configuration Analyst II
Centene
12.2020 - 05.2022
Grievance & Appeals Specialist
Centene
11.2017 - 12.2020
Integrated Specialist
CarePlus Health Plan
02.2013 - 11.2017
Claims Analyst III
Amerigroup Corporation
08.2007 - 01.2013
Claims Benefit Specialist
Aetna Healthcare
01.2007 - 08.2007
Consumer Banker - CSR
Bank of America
02.2004 - 01.2006
Medical Service Representative / Claims Processor
Oxford Health Plans
08.2002 - 01.2004
High School Diploma -
Wharton High School
Some College (No Degree) - Health Information Technology
Hillsborough Community College