CIERRA STATEN
MERIDIANVILLE,AL
Summary
Highly motivated claims examination professional with extensive experience in the insurance and medical industry. Adept at leading teams and optimizing operational efficiencies. Proven efficiency in complex data analysis demonstrating a strong track record in enhancing client satisfaction. Expert in processing a high volume of claims while ensuring accuracy and compliance through auditing and management. Excellent problem-solving and communication skills with a commitment to providing superior customer service. Experienced in processing and auditing CMS 1500, UB04, and pharmaceutical claims utilizing multiple computer systems to maintain accurate records.
Overview
16
16
years of professional experience
Work History
Claims Adjuster
Firstsource Molina
12.2023 - Current
- Evaluate and process claims using complex databases, ensuring accurate payment decisions.
- Extensive assistance with Medicaid, Medicare, and commercial health plans.
- Adjudication and examination of claim forms UB-04 and CMS-1500. Review and coordination of EOBs, EOPs, prior authorizations, and remittance advice.
- Processed claims efficiently, leading to quicker resolutions and enhanced client satisfaction through streamlined workflows like Salesforce and QNXT.
- Evaluated complex claims data to uncover trends, driving proactive adjustments that led to noticeable improvements in processing accuracy.
- Conducted thorough audits on high dollar claims across various platforms, ensuring compliance and accuracy while minimizing payment discrepancies.
Independent Dispute Resolution
Medix/Provider Resources, Inc (PRI)
02.2026 - 02.2026
- Front line of the Independent Dispute Resolution Entity (IDRE) process reviewing and analyzing out-of-network payment disputes between nonparticipating providers and group health plans under the No Surprise Act, while making independent, binding payment determinations.
- Review case documentation and select between proposed payment offers using federal regulatory guidance to make independent, fair, and defensible payment determinations.
- Accurately document decisions and enter data into government portals.
- Collaborates with internal teams to meet quality, accuracy, and productivity metrics.
- Maintain strict confidentiality, compliance, and professionalism.
Corporate Advisor
Best Buy
11.2020 - 04.2025
- Manage high-level support for phone, email, and chat, ensuring customer issues are resolved.
- Handle critical communications, preventing legal actions through effective problem resolution.
- Oversee sales and phone operations, achieving measurable improvements in service efficiency.
- Cultivated a collaborative environment among a team of 12, enhancing morale and fostering a culture of open communication.
- Managed customer retention strategies, leading to substantial improvements in account loyalty and reduced retention rates.
- Provides feedback on call flow metric errors and negative survey response.
- Analyzed call data to identify trends, optimizing response strategies and significantly increasing customer satisfaction metrics.
- Facilitated supervisor-level discussions, resolving escalated issues and ensuring timely solutions that strengthened client relationships.
Claims Adjudicator Specialist
PharMerica
05.2023 - 10.2023
- Investigate and research medical revenue cycle management risks in billing and rebilling processes.
- Managed a portfolio of rejected pharmacy claims, achieving timely billing and minimizing financial risks for PharMerica and its customers.
- Resolved rejected claims by collaborating with Medicare, Medicaid, and commercial plans ensuring adherence to deadlines and maximizing payer reimbursements.
- Executed precise edits and reversals on claims, ensuring accurate submissions and optimizing reimbursement processes.
- Communicated effectively with providers, insurance agencies, third party clients, and customers to gather necessary information via email, chat, and phone, enhancing claims processing efficiency.
- Streamlined billing transactions for non-standard orders, improving accuracy and expediting the claims process.
Reconsideration Analyst II
J29/C2C Innovative Solutions
12.2022 - 04.2023
- Drafts a non-medical LEP decision that is clearly written and understandable, comports with the Centers for Medicare & Medicaid Service (CMS) regulations and policy, and supports the evidence in the record.
- Investigates arguments of creditable coverage offered by enrollees in support of removing a LEP for uncovered months; this includes reviewing enrollee appeal letters, reviewing documents furnished by enrollees in support of proof of creditable coverage, reviewing Part D plan case files, and calling enrollees, employers or other insurers, and Part D plans, as appropriate, to verify creditable coverage.
- Conducts research using online CMS regulations and policy provisions, subscriber materials, and CMS system including the Eligibility and Enrollment Medicare Online (ELMO) to adjudicate decisions that are accurate and well-supported.
- Makes sound, independent decisions on whether there is good cause for late filing of an appeal based on the evidence in the record in accordance with CMS regulations and policies alongside reviewing the enrollee appeal letters and case files submitted by plans.
Data Entry Analyst
BBVA Bank
01.2019 - 10.2020
- Entered and updated business account data, ensuring accuracy and completeness.
- Conducted audits of uploaded files, identifying and resolving discrepancies.
- Secured database integrity through regular backups and data purging.
- Maintained rigorous data entry standards, ensuring timely updates and minimizing discrepancies in customer account information.
- Collaborated with team leaders to resolve data deficiencies, fostering a culture of teamwork and enhancing project outcomes.
Subject Matter Expert
AT&T
02.2015 - 12.2018
- Guided agents in resolving customer queries, enhancing satisfaction and retention.
- Resolved issues through research and alternative solutions, improving problem resolution and sales rates.
- Maintained call center database accuracy, supporting operational efficiency.
- Coached team members on policy changes, fostering a supportive environment that improved overall team performance.
- Analyzed call center data to identify trends, streamlining processes that led to marked improvements in response times.
- Enhanced customer satisfaction by leading training sessions for agents, resulting in improved service delivery and retention rates.
Claims Specialist
Optum RX
04.2013 - 01.2015
- Facilitated communication between pharmacies, insurance providers, and patients, ensuring seamless resolution of payment issues and enhancing service delivery.
- Maintained accurate databases for medication distribution, ensuring timely processing of prescriptions and compliance with quality standards.
- Managed a portfolio of rejected pharmacy claims, achieving timely billing and minimizing financial risks for Optum and its customers.
- Maintained comprehensive databases for medication tracking, ensuring accuracy and adherence to regulatory guidelines, minimizing errors in grievance and appeals submission.
Assistant Supervisor
Title Cash
07.2010 - 08.2012
- Managed loan collections, enhancing recovery rates and improving cash flow.
- Processed payroll bi-monthly, ensuring timely distribution of checks.
- Oversaw vehicle inspections, providing fair offers based on company criteria.
- Orchestrated payment collection strategies, enhancing cash flow and reducing overdue accounts through proactive customer engagement.
- Implemented rigorous credit checks to ensure loan eligibility, significantly minimizing risk and improving the approval process.
- Maintained accurate records of transactions and communications, ensuring compliance and facilitating efficient office operations.
Education
Associates - Business Health Management
Northeast Alabama Community College
11-2028
Registered Nursing -
John C Calhoun State Community College
05-2019
Certificate - Medical Terminology and Information Technology
Marshall Technical School
05-2010
Diploma - undefined
Guntersville High School
05-2010
Skills
- Management
- Claims Processing
- Leadership
- Data Analysis/ Entry
- Auditing
- Independent Dispute Resolutions
- Customer Service
- Case Management
- Insurance
- Quality Assurance
- Risk Management
- Appeals/ Grievance
Timeline
Independent Dispute Resolution
Medix/Provider Resources, Inc (PRI)
02.2026 - 02.2026
Claims Adjuster
Firstsource Molina
12.2023 - Current
Claims Adjudicator Specialist
PharMerica
05.2023 - 10.2023
Reconsideration Analyst II
J29/C2C Innovative Solutions
12.2022 - 04.2023
Corporate Advisor
Best Buy
11.2020 - 04.2025
Data Entry Analyst
BBVA Bank
01.2019 - 10.2020
Subject Matter Expert
AT&T
02.2015 - 12.2018
Claims Specialist
Optum RX
04.2013 - 01.2015
Assistant Supervisor
Title Cash
07.2010 - 08.2012
Certificate - Medical Terminology and Information Technology
Marshall Technical School
Diploma - undefined
Guntersville High School
Associates - Business Health Management
Northeast Alabama Community College
Registered Nursing -
John C Calhoun State Community College