Derenisha Sutton
Walker,LA
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
6
6
years of professional experience
1
1
Certification
Work History
Grievance and Appeal Specialist
Humana
09.2021 - Current
- Responsible for daily handling of casework, including processing of new cases, coordinating open cases to resolution and entering closing casework notes to resolve cases
- Researches issues utilizing systems and clinical assessment skills, knowledge and approved Decision Support Tools in the decision making process regarding health care services and care provided to members, and Marketplace enrollment issues
- Assures timeliness and appropriateness of all case resolutions according to state and federal and Healthcare guidelines
- Requests and obtains enrollment history, claims history and/or invoices as appropriate to assist with research.
Inbound Contact Representative- Call Center (Medicaid/Medicare)
10.2019 - 09.2021
- Proficient in CRM, CAS, CIS PRO software
- Ability to navigate multiple computer applications
- Interpret claims, submission, timely filing, status explanation and payment entail
- Providers Authorization and Referral requirements and status
- Grievance & Appeals/Disputes status, Correspondence request information (address,fax,availity portal)
- Certified Subject Matter Expert
Rooms Controller
Harrah’s Hotel
05.2018 - 10.2019
- Fulfilling guest room requests based on pre-arranged requests upon arrival, VIP, and group reservations through LMS System
- Checking in reservations, assigning room keys, room inventory at front desk
- Facilitate pre-shift meeting with projected daily goals
- Communicate through Ivy system; Ivy reads incoming guest texts and directs them to the correct hotel department
- Credit card transactions, and reviewing credit card reports for duration of guest stay
Education
High School Diploma -
Edna Karr High School
New Orleans, LAMedical Billing And Coding - Healthcare
Unitech Training Academy - Lafayette
Lafayette, LA10.2023
Skills
- Attention to Detail and Quality-Oriented
- Ability to communicate clearly and professional with diverse populations
- Skilled in Software
- Quick and precise problem solving
- Ability to multi-task
- Great team participant and shift leader
- Entering Patient Demographics
- Insurance Verification and Pre-Authorization
- Patient Referrals
- Critical Thinking
- Medical Coding
- Documentation skills
Awards
- Associate of the Year - Wyndham Avenue Plaza 2017
- Associate of the Month - Wyndham Avenue Plaza February 2018
- Associate of the Month- Wyndham Avenue Plaza January 2016
- Associate of the Month- Harrah’s Hotel December 2018
Volunteer Experience
- Creekstone Academy, Kennesaw, GA, Teacher/Floater, 09/2013, 02/2014
- Kingsley House, New Orleans, LA, 08/2014, 12/2015
- Second Harvest Food Bank, 05/2017
Certification
- CCA - Certified Coding Associate
Timeline
Grievance and Appeal Specialist
Humana
09.2021 - Current
Inbound Contact Representative- Call Center (Medicaid/Medicare)
10.2019 - 09.2021
Rooms Controller
Harrah’s Hotel
05.2018 - 10.2019
High School Diploma -
Edna Karr High School
Medical Billing And Coding - Healthcare
Unitech Training Academy - Lafayette