Diamond Walker
Dayton,OH
Summary
Objectives: Dedicated to addressing organizational challenges and contributing to a forward-thinking company by leveraging skills while managing multiple priorities in a changing environment. Seeking a demanding role that offers opportunities for growth and advancement, while also making meaningful contributions to the community. Experienced Grievance & Appeals Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering over 8 years of experience and willingness to take on any challenge.
Overview
16
16
years of professional experience
Work History
Provider Appeals Specialist II
CareSource
03.2019 - Current
- Proficiently process daily provider appeals received via fax, mail, or provider portal for Ohio and Georgia Medicaid members
- Identify and document systemic issues, initiating tickets and monitoring their progress
- Proven ability to effectively communicate, both in person and in writing, with strong interpersonal skills
- Accurately adjudicate medical and facility claims for Medicaid members following appeal determinations
- Thoroughly review claims for potential fraud and abuse, reporting findings to SIU
- Provided insights to Team Lead regarding prospective new hires
- Reviewed logs for all networking devices for unresolved abnormalities and problems
- Collaborate with Cotiviti to resolve disputes by preparing and submitting packets with medical records
- Instructed team on claim processing and documentation through Facets and Guiding Care
- Developed appeals functions, policies and procedures and documentation
- Monitored network hardware operations to evaluate proper configuration
Claims Analyst
CareSource
10.2017 - 03.2019
- Accurately processed medical and facility claims for Medicare, Medicaid, and Behavioral Health beneficiaries
- Researched and managed Coordination of Benefits (COB) claims
- Handled claims processing, adjustments, and recoveries
- Supported additional job-related functions upon request
- Conducted audits for newly hired employees
- Provided shadowing and guidance for new hires
- Joined Behavioral Health team during its launch in July 2018
- Excellent problem solving, organizational and analytical skills
- Maintained strict confidentiality with all personal data as per company guidelines
- Viewed reports regularly to make sure processing was conducted efficiently
Subject Matter Expert
CareSource
01.2017 - 10.2017
- Assisted customer service representatives across all lines of business by answering queries
- Produced reports for Team Lead as required
- Mentored fellow customer care representatives
- Aided over 20 new hires in setting up computers post-training
- Skilled in querying and data analysis
- Conducted training on Cisco Agent Desktop
- Conducted side-by-side sessions with advocates needing improvement
- Resolved 100% of escalated calls promptly, ensuring follow-up and resolution
- Provided support for Georgia Outbound Campaign
- Trained about 30 advocates on Community Transition Program (CTP) line of business
- Notified Team Leads of advocate misconduct via email.
- Analyzed business problems, identifying root causes and developing robust solutions.
- Strong technical and communication skills (written and verbal)
Customer Care Advocate
CareSource
02.2016 - 01.2017
- Addressed member inquiries regarding eligibility and benefits
- Assisted in test calls for quality assessment
- Provided backup support for fellow advocates of 100 or more.
Housekeeping Attendant
Soin Medical Center
01.2014 - 02.2016
- Maintained daily cleanliness of over 40 patient rooms and common areas
- Cleaned designated areas as assigned
- Ensured proper sanitation of discharged patient rooms
Cashier
Kroger, 2115 E. Dorothy Ln
11.2009 - 12.2014
- Provided exceptional customer service while handling payments for groceries
- Ensured efficient and professional service to customers
Food and Beverage Associate
Kings Island
05.2007 - 10.2009
- Delivered top-notch food service to park visitors, catering to their needs
- Handled money that was made on days that lasted over 12 hours in one shift
- Greeted customers with friendly and exceptional customer service
Education
Undergraduate - Nursing, Studies
Sinclair Community College
Dayton2016
Undergraduate - Nursing
University of Akron
Akron2014
Diploma -
Chaminade Julienne High School
Dayton, OH2011
Skills
- Meticulous and detail-oriented
- Proficient in advising on and resolving complex and non-complex, well-precedented factual, procedural, and recurring issues
- Adept at multitasking in fast-paced settings, consistently meeting project deadlines
- Exceptional customer service skills and proficiency in MS Word, Excel, Outlook, OneNote, and PowerPoint
- Proficient in tools such as Okta, Workday, Guiding Care, Cotiviti, and Facets
- Superior analytical skills
- Ability to prioritize and maintain quality
- Data Entry
- Small & Large Claims Payouts
- Ability to work independently
- Technical Documentation
- Superb Interpersonal Skills
Accomplishments
- Collaborated with team of Clinical in the development of Resolving members bills that were reported over 60 days.
- Collaborated with my Team Leader to create a step-by-step manual to guide my fellow co-workers on how to ask the appropriate questions in our Team chat.
Timeline
Provider Appeals Specialist II
CareSource
03.2019 - Current
Claims Analyst
CareSource
10.2017 - 03.2019
Subject Matter Expert
CareSource
01.2017 - 10.2017
Customer Care Advocate
CareSource
02.2016 - 01.2017
Housekeeping Attendant
Soin Medical Center
01.2014 - 02.2016
Cashier
Kroger, 2115 E. Dorothy Ln
11.2009 - 12.2014
Food and Beverage Associate
Kings Island
05.2007 - 10.2009
Undergraduate - Nursing, Studies
Sinclair Community College
Undergraduate - Nursing
University of Akron
Diploma -
Chaminade Julienne High School