Daniya Holmes
ADP
Phoenix,AZ
8
years of professional experience
Healthcare operations professional with 6+ years of experience supporting claims processing, revenue cycle, prior authorization, insurance operations, and benefits administration. Recognized for resolving complex issues, managing high-volume caseloads, and delivering exceptional service to members, providers, clients, and cross-functional partners. Skilled at investigating discrepancies, interpreting policies, ensuring regulatory compliance, and driving accurate, timely resolutions in fast-paced healthcare environments.
Work History
Benefit Operations Specialist
1 Year 3 Months- Manage a high-volume caseload by investigating and resolving complex employee benefits inquiries related to eligibility, enrollments, life events, payroll deductions, and carrier discrepancies.
- Research account history, analyze documentation, and interpret plan provisions to identify root causes and determine accurate resolutions while ensuring compliance with company policies and benefit regulations.
- Process benefit transactions, including enrollments, qualifying life events, coverage changes, terminations, and corrections with a high level of accuracy and attention to detail.
- Collaborate with insurance carriers, internal departments, HR administrators, and clients to resolve benefit discrepancies and ensure timely case resolution.
- Utilize Salesforce and ADP Workforce Now to document case activity, maintain accurate records, and manage workload priorities while meeting service level agreements (SLAs).
- Educate clients and employees on benefit plans, eligibility requirements, enrollment guidelines, and available coverage options while delivering exceptional customer service.
- Review supporting documentation to verify eligibility and ensure compliance with federal regulations, company policies, and benefit plan requirements.
- Prioritize competing deadlines while consistently meeting productivity, quality, and turnaround time expectations in a fast-paced operations environment.
- Maintain strict confidentiality by safeguarding sensitive employee and health information in accordance with HIPAA, privacy standards, and organizational policies.
- Recognized for strong quality, accuracy, and customer service by consistently delivering timely, compliant, and effective case resolutions.
Prior Authorization Specialist
1 Year 9 Months- Reviewed and processed prior authorization requests to ensure complete clinical documentation and compliance with payer requirements.
- Verified patient insurance eligibility, prescription benefits, and coverage for commercial, Medicare, and Medicaid health plans.
- Collaborated with healthcare providers, pharmacies, and insurance carriers to obtain authorization approvals and resolve coverage-related issues.
- Investigated claim rejections and prior authorization denials by reviewing payer guidelines, clinical documentation, and patient account information.
- Maintained accurate documentation of authorization status, payer communications, and case activity within internal systems.
- Educated patients and provider offices on insurance requirements, authorization processes, coverage determinations, and next steps while delivering exceptional customer service.
- Coordinated with cross-functional teams to expedite urgent medication access and minimize delays in patient treatment.
- Managed a high-volume workload while meeting productivity, quality, and turnaround time expectations in a fast-paced healthcare environment.
- Ensured compliance with HIPAA regulations, payer policies, and organizational standards while handling protected health information.
Customer Care Representative
10 Months- Assisted members, providers, and healthcare professionals by resolving complex inquiries related to health insurance benefits, eligibility, claims, and coverage.
- Researched member accounts and insurance records to investigate issues, identify root causes, and provide accurate, timely resolutions.
- Interpreted health plan benefits, policies, and payer guidelines to explain coverage decisions and available healthcare services.
- Documented customer interactions, case details, and resolutions while maintaining accurate records and compliance with HIPAA and organizational standards.
- Collaborated with internal departments to resolve claim-related concerns, benefit discrepancies, and member account issues.
- Verified member eligibility, benefits, and plan information to ensure accurate guidance and efficient issue resolution.
- Delivered exceptional customer service by educating members on healthcare benefits, claims processes, and next steps while maintaining professionalism and empathy.
- Managed a high-volume workload while consistently meeting quality, productivity, and service performance expectations.
- Protected confidential health information and adhered to all HIPAA, regulatory, and company compliance requirements.
Claims Processing Associate
2 Years 5 Months- Processed medical insurance claims for commercial, Medicare, and Medicaid payers while ensuring accurate claim submission and timely reimbursement.
- Verified insurance eligibility, benefits, and authorization requirements prior to claim processing to minimize denials and payment delays.
- Reviewed and resolved claim edits, rejections, and denials by researching account history, payer guidelines, and supporting documentation.
- Investigated claim discrepancies and coordinated with insurance carriers to resolve billing issues, payment variances, and outstanding claim balances.
- Reviewed Explanation of Benefits (EOBs) and remittance advice to reconcile payments, identify reimbursement discrepancies, and support revenue cycle accuracy.
- Maintained detailed documentation of claim activity, payer communications, account updates, and resolution outcomes within the billing system.
- Collaborated with providers, clinical staff, and revenue cycle team members to obtain supporting documentation and facilitate accurate claims processing.
- Communicated with patients and insurance representatives to explain claim status, coverage, financial responsibility, and next steps while delivering exceptional customer service.
- Managed a high-volume workload by prioritizing accounts, meeting productivity expectations, and ensuring timely follow-up on outstanding claims.
- Maintained compliance with HIPAA regulations, payer requirements, and organizational policies while handling confidential patient and financial information.
Medical Assistant
7 Years 11 Months- Verified patient demographic and insurance information, including commercial, Medicare, and Medicaid coverage, to support accurate registration and reimbursement.
- Coordinated insurance authorizations, referrals, and appointment scheduling while ensuring compliance with payer and provider requirements.
- Utilized Epic electronic health record (EHR) to document patient encounters, review medical records, update insurance information, and maintain accurate clinical documentation.
- Assisted providers with patient examinations, clinical procedures, medication administration, and collection of vital signs in a fast-paced primary care setting.
- Educated patients on treatment plans, referral requirements, insurance processes, and follow-up care while delivering compassionate, patient-centered customer service.
- Collaborated with physicians, specialists, referral coordinators, and insurance representatives to resolve authorization, scheduling, and documentation issues.
- Maintained HIPAA compliance by safeguarding confidential patient information and ensuring accurate medical record documentation.
- Supported daily clinic operations by prioritizing patient flow, preparing examination rooms, managing medical supplies, and contributing to efficient healthcare delivery.
Education
Bachelor of Science - Health Administration
Associate of Science - Health Administration
High School Diploma
Skills
Claims Processing & Insurance Operations: Medical Claims Processing • Claims Investigation • Claims Resolution • Denial Management • Prior Authorization • Insurance Verification • Eligibility Verification • Benefits Administration • Revenue Cycle Management (RCM) • Explanation of Benefits (EOB) Review • Appeals Support • Healthcare Operations • Payer Guidelines • Commercial
Medicare & Medicaid Plans
Case & Customer Management: Case Management • Customer Service • Member & Provider Support • Client Relationship Management • Issue Resolution • Escalation Management • Cross-Functional Collaboration • Conflict Resolution • Written & Verbal Communication
Compliance & Documentation: HIPAA Compliance • Regulatory Compliance • Policy Interpretation • Documentation Review • Records Management • Quality Assurance • Audit Support • Process Improvement • Root Cause Analysis • Data Accuracy • Attention to Detail
Technical Skills: Epic EHR • Cerner • ClinicalWorks (eClinicalWorks) • Salesforce • ADP Workforce Now • Microsoft Office Suite (Excel
Word
Outlook
PowerPoint) • Microsoft Teams • Case Management Systems • Electronic Health Records (EHR) • Data Entry • Document Management Systems
Core Competencies: Analytical Problem Solving • Critical Thinking • Time Management • Organization • Multitasking • High-Volume Workload Management • Adaptability • Decision Making • Accuracy • Team Collaboration
Timeline
Benefit Operations Specialist
ADP
04.2025 - CurrentRead More
Prior Authorization Specialist
PhilRx
07.2023 - 04.2025Read More
Customer Care Representative
Elevance Health
09.2022 - 07.2023Read More
Claims Processing Associate
Affiliated Urologist
02.2021 - 07.2023Read More
Medical Assistant
Community Health Center
08.2018 - 2022Read More
Grand Canyon University
Bachelor of Science from Health Administration
Read More
Colorado Christian University
Associate of Science from Health Administration
Read More
Griswold High School
High School Diploma
Read More