Cheryl Walker

• Research and resolve incoming electronic appeals as appropriate as a “single-point-of-contact” based on type of appeal.

• Can identify and reroute inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work.

• Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures.

• Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial.

• Can review a clinical determination and understand rationale for decision.

• Able to research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to the initiation of the appeal process.

• Serves as point person for newer staff in answering questions associated with claims/customer service systems and products. Educates teammates as well as other areas on all components within member or provider/practitioner complaints/appeals for all products and services.

• Coordinates efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise.

• Identifies trends and emerging issues and reports on and gives input on potential solutions.

• Delivers internal quality reviews, provides appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required.

• Understands and can respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned.