De'ja Evette Garth
Harper Woods
Summary
Results-driven Claims Resolution Specialist with extensive experience in claim analysis, negotiation strategies, and regulatory compliance within health care. Achieved high levels of productivity and efficiency through effective problem-solving and decision-making in complex claims environments. Committed to aligning efforts with organizational goals and values while managing caseloads to ensure optimal outcomes.
Overview
13
13
years of professional experience
Work History
Claims Resolution Specialist - Promotion
Ascension
02.2024 - Current
- Reviews and responds to escalated internal and external calls and emails from participants, providers and provider reps.
- Reviewed provider fee schedules to resolve payment discrepancies for providers referred by provider relations team or client, ensuring accurate payments.
- Researches root cause issues and delivers resolutions to the client.
- Generated impact reports to analyze and troubleshoot errors in provider fee schedules and claims processing, facilitating timely resolutions for stakeholders.
- Analyzed claims for accuracy and compliance with policies.
- Communicated with clients to resolve inquiries and issues.
- Identified trends in claims discrepancies to provide actionable insights for reporting and process improvements.
- Assisted in developing best practices for claims management processes.
- Processed claims using specialized software systems efficiently.
- Processed payments, refunds, and adjustments.
- Utilized Jira daily to manage project tasks and workflows.
- Reviewed , Researched and Adjusted Complex Claims
Claims Adjuster
Ascension
02.2023 - 01.2024
- Research and review assigned claims by navigating multiple platforms capturing the data/information necessary for processing
- Communicate regarding adjustments to resolve claim errors
- Complete necessary adjustments to claims and ensure proper benefits are applied to each claim by using appropriate process and procedures
- Communicate with broad audience to support applicable procedures
Referral Specialists I
Meridian Health Plan
10.2018 - 02.2023
- Receive and organize authorization requests and clinical information via fax or telephone for all lines of business as needed
- Enter a system approval for all PCP authorizable services
- Assist in the collection of HEDIS data
- Understand principles of HIPAA and maintain confidentiality. Perform other duties as assigned such as faxing, filing and mailing
- Make outgoing calls to members to conduct outreach related to MHP clinical priorities
- Forward corporate authorization requests and accompanying clinical information to licensed reviewers
- Initiate authorization requests for outpatient and inpatient services in accordance with the prior authorization list. Route to appropriate staff when needed
Claims Examiner- Promotion
Molina Healthcare, Inc.
11.2014 - 10.2018
- Processing medical claims (Inpatient/Outpatient)
- Ensure Legal Compliance
- Approve and Deny Insurance Claims
- Provided Training to New Hires
- Analyzed/processed adjudication of fees for services for the states of Illinois/Florida
- Processed 150+ Claims Daily
- Investigate and Evaluate Medicaid and Medicare Claims
Member Service Representative
Molina Healthcare, Inc.
08.2013 - 11.2014
- Resolved product/service issues to enhance customer satisfaction
- Proposed optimal solutions for claimants to facilitate efficient resolution
- Streamlined adjustment procedures to enhance efficiency
- Addressed and fulfilled customer needs to improve service experience
Education
Bachelor of Science - Business Administration
Central State University
OhioSkills
- Expert in Claims Processing
- Claims analysis
- Claims investigation
- Adjustments processing
- Fee schedule analysis
- Regulatory knowledge
- Automated pricing
- Insurance terminology
- Data analysis tools
- Root cause analysis
- Problem solving
- Attention to detail
- Time management
- Written and verbal communication
- Effective communication
- Self-motivated
- Fast-paced self-starter
Timeline
Claims Resolution Specialist - Promotion
Ascension
02.2024 - Current
Claims Adjuster
Ascension
02.2023 - 01.2024
Referral Specialists I
Meridian Health Plan
10.2018 - 02.2023
Claims Examiner- Promotion
Molina Healthcare, Inc.
11.2014 - 10.2018
Member Service Representative
Molina Healthcare, Inc.
08.2013 - 11.2014
Bachelor of Science - Business Administration
Central State University