Summary
Overview
Work History
Education
Skills
Websites
Timeline
Generic

Dawna Leamon

North Richland Hills,TX

Summary

Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. To seek and maintain a full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. Successful at reviewing suspicious activities and uncovering fraud. Excellent reporting and documentation skills. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Knowledgable and dedicated customer service professional with extensive experience in health insurance industry. Solid team player with positive demeanor and proven skills in establishing rapport with clients. Motivated to maintain customer satisfaction and contribute to company success. Specialize in quality, speed and process optimization. Articulate, energetic, and results-oriented with exemplary passion for developing relationships, cultivation partnerships and growing businesses. Hard working, self sufficient, highly motivated team player with 32 years in the health insurance industry. Easily adjusts to changes in workplace environment and procedures. Microsoft Office, Microsoft Word, Excel. Proficient in medical terminology, contract language and state mandates. Processed claims in AS400 and RIMS settings. Quality Control. Proficient in medical terminology, contract language and state mandates. ICD-10. Insurance Verification. Medical Records. ICD-9. Improvement recommendations. Deductive reasoning. Data Analysis. Consultative support. Quality Processes. Call monitoring. Quality Assurance. Atliassan. Verint. Five9

Overview

10
10
years of professional experience

Work History

Quality Assurance Analyst

UnitedHealth Group
11.2016 - 05.2023
  • Audit large dollar, exclusion, waiting period and pre-existing investigation claim files for review, release or referral to Upper Management
  • Listen to customer service calls to determine if quality guidelines were followed
  • Refer to Management for review and to take proper action to correct the issues as necessary
  • Weekly meetings with Department Managers to discuss findings of call monitoring and Excel reporting
  • Excel reporting of training opportunities for different Departments
  • Premium handling
  • Medical records review
  • Processed unclaimed funds checks for Members and Providers and reissued them to correct addresses.
  • Supported company in maintaining work environment focused on quality, communication, collaboration, integration, and teamwork
  • Created and achieved product quality objectives and met product specifications
  • Mentored and coached team members on QA topics and strategies
  • Assisted teammates in developing skills necessary to grasp application concepts
  • Wrote and maintained detailed internal documentation on developed systems

Claims Risk Analyst

US HealthGroup
09.2015 - 11.2016
  • Begin pre-existing investigations on potential Member's wishing to upgrade their benefits
  • Review phone logs by Upgrade Analysts to retrieve information regarding medical conditions and physicians seen
  • Request claim forms from Members, medical records from physicians and facilities to begin investigations
  • Follow up with requests (via phone, fax, US mail) to Members, physicians and facilities
  • Determine eligibility of Upgrades
  • Forward to Claims Analysts for processing
  • Investigated allegations to check validity and recommend actions to minimize risk
  • Produced and filed reports to inform senior management of current activities and progress with investigations.

Customer Service Analyst

US HealthGroup - Assumed By UnitedHealth Group
02.2013 - 09.2015
  • Answer telephone calls from Members, Providers and Agents in regards to coverage, premiums and claims status and processing
  • Audit claims processed by claims analysts
  • Request check tracers on outstanding claim payments
  • Process cancellations on policies (Paid to date and pro-rated)
  • Work in a timely and efficient manner to complete telephone calls
  • Provided primary customer support to internal and external customers
  • Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns
  • Answered product and service questions, suggesting other offerings to attract potential customers
  • Answered constant flow of customer calls with minimal wait times
  • Consulted with outside parties to resolve discrepancies and create expert solutions
  • Investigated and resolved customer inquiries and complaints quickly
  • Developed highly empathetic client relationships and earned reputation for exceeding service standard goals
  • Maintained up-to-date knowledge of product and service changes
  • Met customer call guidelines for service levels, handle time and productivity
  • Followed-through on all critical inter-departmental escalations to increase customer retention rates
  • Delivered prompt service to prioritize customer needs
  • Work in a timely and efficient manner to complete telephone inquiries

Education

Richland High School - North
Richland, TX
1988

Skills

  • Deductive Reasoning
  • Quality Assurance
  • Call Monitoring
  • Data Analysis
  • Mentoring and Training
  • Process Implementation
  • Critical thinking abilities
  • Attention to detail
  • Quality management knowledge
  • Time Management and Organization
  • Strong Problem Solver
  • Decision-Making
  • Verint
  • Five9

Timeline

Quality Assurance Analyst

UnitedHealth Group
11.2016 - 05.2023

Claims Risk Analyst

US HealthGroup
09.2015 - 11.2016

Customer Service Analyst

US HealthGroup - Assumed By UnitedHealth Group
02.2013 - 09.2015

Richland High School - North
Dawna Leamon