Clarence Washington
Houston,US
Summary
Medicaid Appeals Specialist with extensive experience in appeals management and data analytics at Baylor Miraca Genetics Laboratories. Streamlined processes to improve patient satisfaction and ensure compliance with CMS guidelines. Strong written communication skills and dedication to customer service and grievance resolution.
Overview
10
10
years of professional experience
Work History
Medicaid Appeals Specialist
Baylor Miraca Genetics Laboratories
11.2024 - Current
- Resolved member and provider complaints by adhering to CMS guidelines.
Analyzed clinical data and prepared coding appeals from patient medical records.
Drafted compelling narratives for Medicare and Medicaid appeals briefs to strengthen cases.
Developed structured appeals, patient correspondences, and payer communications.
Effectively communicated resolutions to ensure understanding among members and providers.
Performed in-depth reviews of appeal submissions to improve accuracy and effectiveness.
Engaged with multidisciplinary teams to optimize complaint resolution workflows.
Senior Claims Analyst II
Medcost
06.2024 - 11.2024
- Calculated premiums, refunds, commissions, and adjustments using insurance rate standards.
- Acted as subject matter expert for non-standard coverage, property damage, and collision inquiries.
- Managed policy modifications and updates to ensure accuracy and compliance.
- Delivered customer service support by addressing inquiries from members, providers, employers, and insurance carriers.
- Assisted claimants and providers in resolving questions regarding claims processing.
- Evaluated pending claims to identify issues hindering auto-adjudication.
Grievance Appeals Specialist
Baylor Scott & White
Houston, TX
03.2023 - 06.2024
- Resolved patient appeals, ensuring adherence to healthcare regulations and enhancing satisfaction.
- Collaborated with departments to address concerns, improving service quality and building patient trust.
- Utilized data analytics to identify trends, driving process improvements and minimizing grievances.
- Streamlined appeals process, reducing resolution time and boosting patient satisfaction scores.
- Maintained confidentiality of patient documentation, ensuring compliance with HIPAA regulations.
- Conducted comprehensive research on appeals, grievances, and complaints to meet regulatory timelines.
- Reviewed medical records and bills to formulate conclusions per protocol and business partners.
- Applied contract language and benefits while contacting members/providers through written communication.
SENIOR MEDICAL CLAIMS PROCESSOR
Triada
Houston, TX
10.2021 - 03.2023
- Processed 100+ claims daily, ensuring high accuracy and client satisfaction.
- Enhanced training programs, boosting team collaboration and engagement.
- Implemented tech solutions, reducing errors and costs, improving efficiency.
- Led team exercises to increase productivity and foster collaboration.
- Oversaw initiatives that significantly improved efficiency and reduced errors.
CUSTOMER SERVICE REPRESENTATIVE
Cigna
Houston, TX
08.2019 - 09.2021
- Resolved customer inquiries swiftly, boosting satisfaction and retention.
- Processed billing and claims accurately, ensuring seamless transactions.
- Collaborated with team to enhance operational efficiency.
- Identified customer needs, recommended services, increased revenue.
- Implemented retention strategies, improved customer loyalty significantly.
PATIENT ACCOUNT REPRESENTATIVE
UT Health
Houston, TX
01.2019 - 08.2019
- Provided empathetic support, effectively addressing customer concerns.
- Mentored team members on best practices for customer engagement and issue resolution.
- Resolved billing inquiries efficiently, enhancing client satisfaction and retention.
- Collaborated with teams to ensure precise billing, reducing errors significantly.
- Tracked client data using CRM, improving information accuracy and accessibility.
APPEALS AND GRIEVANCE REPRESENTATIVE
United Healthcare
Houston, TX
11.2014 - 01.2019
- Reviewed member appeals, ensuring compliance and resolving issues promptly.
- Collaborated with teams to enhance response times and member satisfaction.
- Streamlined processes, resulting in faster resolution and improved efficiency.
- Used data analytics to uncover trends, aiding in strategic decision-making.
- Analyzed appeals data to identify trends, providing insights for process improvements and informed decision-making.
Education
Bachelor of Arts - Communications
Southern New Hampshire University
12.2024
Skills
- Appeals management
- Customer service and support
- Health care compliance and regulations
- CMS guidelines
- Policy writing
- CMS guidelines adherence
- CMS Guidelines Familiarity
- HCPCS coding guidelines
- Grievance resolution
- Data analytics
- Process improvement
- Patient satisfaction
- Claims processing
- Account management
- Effective communication
- Written communication
Timeline
Medicaid Appeals Specialist
Baylor Miraca Genetics Laboratories
11.2024 - Current
Senior Claims Analyst II
Medcost
06.2024 - 11.2024
Grievance Appeals Specialist
Baylor Scott & White
03.2023 - 06.2024
SENIOR MEDICAL CLAIMS PROCESSOR
Triada
10.2021 - 03.2023
CUSTOMER SERVICE REPRESENTATIVE
Cigna
08.2019 - 09.2021
PATIENT ACCOUNT REPRESENTATIVE
UT Health
01.2019 - 08.2019
APPEALS AND GRIEVANCE REPRESENTATIVE
United Healthcare
11.2014 - 01.2019
Bachelor of Arts - Communications
Southern New Hampshire University
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