ESSENCE DANIELS
Fairfield,NJ
Summary
Healthcare Operations and Claims Professional with 10+ years of experience supporting healthcare insurance operations, claims review, prior authorization processing, eligibility determinations, appeals and grievances, and compliance programs. Experienced working with Medicare, Medicaid, ACA, and commercial insurance plans while maintaining HIPAA compliance and regulatory standards. Proven ability to analyze complex cases, review medical documentation, resolve discrepancies, and manage high-volume workload with exceptional accuracy and attention to detail. Skilled in claims processing, benefit determinations, case management, and healthcare information systems including Salesforce Health Cloud, IBM Curam, and Microsoft Dynamics.
Overview
7
7
years of professional experience
1
1
Certification
Work History
Fraud & Disputes Analyst
Discover Financial Services
Remote
06.2025 - Current
- Investigated disputes, account discrepancies, and claim-related issues while ensuring regulatory compliance and accurate case resolution.
- Review account documentation, transaction histories, and supporting records to determine claim validity and appropriate outcomes.
- Analyzed complex data from various sources to determine claim outcomes.
- Maintained detailed case documentation and audit-ready records while ensuring compliance with company policies and regulatory requirements.
- Collaborated with internal departments to resolve complex cases and improve operational efficiency.
Coverage Review Associate
Cigna
Remote
09.2022 - 03.2024
- Reviewed prior authorization requests and benefit eligibility for Medicare, Medicaid, and commerical health plans
- Evaluated medical documentation to support coverage determinations and healthcare service authorizations.
- Researched claim-related inquires, benefit requirements, and healthcare policies to ensure accurate processing.
- Assisted with appeals and grievance reviews while maintaining regulatory compliance.
- Processed high-volume healthcare cases while meeting quality, productivity, and accuracy standards.
- Maintained provider records and case documentation in Salesforce Health Cloud.
Eligibility Specialist (Contract)
Arkansas Department of Human Services
Remote
05.2021 - 08.2022
- Processed 40–60 Medicaid applications weekly with 99% accuracy in IBM Curam and Microsoft Dynamics.
- Verified documentation, analyzed case data, and determined eligibility for Medicaid applicants.
- Reduced processing delays by 30% through accurate data entry and discrepancy resolution.
- Determined eligibility and benefit qualifications for Medicaid applicants.
Healthcare Enrollment & Eligibility Specialist
Get Covered NJ
Remote
12.2019 - 03.2021
- Assisted consumers with insurance applications and updates in Salesforce CRM.
- Processed 50–70 applications daily with 95%+ accuracy.
- Resolved eligibility discrepancies, account issues, and enrollment changes.
Disputes Analyst (Contract)
Global Payments
Remote
11.2023 - 04.2024
- Processed 50+ daily financial transactions, transfers, and updates with 99.8% accuracy.
- Maintained detailed logs and documentation for audits and reporting.
- Validated high-volume customer data for fraud prevention and compliance reporting.
Dental Assistant
The Smilist
Clifton, New Jersey
04.2024 - 05.2025
- Maintained patient records, treatment documentation, and HIPAA-compliant clinical records using Dentrix/Open Dental software.
- Managed digital records and documentation for 15+ patients daily.
- Ensured compliance with HIPAA while handling confidential patient information.
Education
Bachelor of Science - Healthcare Administration
Southern New Hampshire University
05-2028
Dental Assisting Certificate - Dental Assistant
American Institute
Clifton, NJ06-2025
Skills
- Claims Review & Processing
- Prior Authorization Management
- Appeals & Grievances
- Eligibility Verification
- Denials Resolutions
- Benefit Determinations
- Medicare & Medicaid Programs
- HIPAA Compliance
Certification
- CPR
- Medical Billing and Coding Fundamentals
Timeline
Fraud & Disputes Analyst
Discover Financial Services
06.2025 - Current
Dental Assistant
The Smilist
04.2024 - 05.2025
Disputes Analyst (Contract)
Global Payments
11.2023 - 04.2024
Coverage Review Associate
Cigna
09.2022 - 03.2024
Eligibility Specialist (Contract)
Arkansas Department of Human Services
05.2021 - 08.2022
Healthcare Enrollment & Eligibility Specialist
Get Covered NJ
12.2019 - 03.2021
Bachelor of Science - Healthcare Administration
Southern New Hampshire University
Dental Assisting Certificate - Dental Assistant
American Institute