DORA RAIDEN CAMPBELL
Tacoma,WA
Summary
Healthcare professional with 7+ years of experience at Molina Healthcare, including 6 years in appeals and grievances and prior claims processing experience. Experienced in analyzing claims and provider data using QNXT and Claim Viewer. Highly detail-oriented, organized, and skilled at reviewing complex information to ensure accuracy, compliance, and process improvement. Committed to learning new systems and taking on data-focused responsibilities.
Overview
13
13
years of professional experience
Work History
Appeals & Grievances Coordinator
Molina Healthcare of WA
Bothell , WA
12.2019 - Current
- Process appeals regarding denied health services such as imaging/radiology, medications, therapies, inpatient services, member reimbursement requests for services rendered by out of-network providers, etc.
- Act as liaison between external health care providers and medical directors when processing appeals
- Make outreach to members and providers to inform on status of their appeal request(s) and advise on any questions/concerns
- Input data entry utilizing multiple internal healthcare systems
- Ensure all appeal requests are processed and completed within turnaround time to meet state criteria and patient care needs
Care Review Processor
Molina Healthcare of WA
Bothell, WA
11.2016 - 12.2019
- Provided telephone, clerical, and data entry support for Care Review team (Prior Authorizations/Utilization Management Dept.)
- Assisted with provider inquiries such as eligibility and benefits verification, provider contracting status, diagnosis and treatment requests, coordination of benefits status determination, hospital census information regarding admissions and discharges, and assistance with providing information on CPT/HCPCS codes, and ICD 10 diagnosis codes
- Worked with multiple provider offices and pharmacies to inquire on necessary prior authorization requests
- Contacted physician offices to request missing information pertaining to authorization requests and request additional information as needed by the company’s Medical Director to make determination on authorizing services
- Ensured prior authorization requests were completed within turnaround time to meet state regulations and guidelines
Member Services Rep/Claims Rep
Molina Healthcare of WA
Bothell, WA
05.2013 - 10.2016
- Responded to over 50 incoming calls from members and healthcare providers as required to meet departmental goals daily
- Provided benefits and eligibility information for both providers and members
- Accurately/thoroughly documented incoming and outbound calls
- Cooperated with other departments as needed to reconcile certain issues with member accounts
- Completed primary care physician changes (PCP) and demographic changes to keep all members files current and up to date
- Assisted with complaint calls and de-escalated volatile situations
- Examined claims issues and sent back claims for reprocessing/adjustment when appropriate
Education
High School Diploma -
Cascade High School
Everett, WA06-2008
Skills
- Typing speed of 75 wpm
- Customer-service oriented
- Outstanding attendance and punctuality
- Self-motivated
- Flexible and adaptable
Well-versed in Microsoft programs/applications such as: MS Word, Excel, OneNote, Outlook, Teams, and PowerPoint
Has knowledge with: Nitro Pro Software, Pega UM, New Century Health, Periscope database system, and Qnxt system
NOTABLE TRAITS:
- Excellent interpersonal and communication skills
- Strong written and oral skills
- Commendable work ethic
- Independent worker who takes initiative
- Ability to multi-task
- Process and detail oriented
- Dependable
Timeline
Appeals & Grievances Coordinator
Molina Healthcare of WA
12.2019 - Current
Care Review Processor
Molina Healthcare of WA
11.2016 - 12.2019
Member Services Rep/Claims Rep
Molina Healthcare of WA
05.2013 - 10.2016
High School Diploma -
Cascade High School