Felicia Wilson
Belleville,IL
Summary
I have over 20 years’ experience in health insurance specific to Provider Services. My goal is to utilize and develop my current skills, while continuing to acquire new experience, to reinvent myself for the future of healthcare.
Overview
27
27
years of professional experience
Work History
Provider Payment Appeal Analyst II OPW
Anthem
01.2024 - Current
- Supports the payment dispute process across all lines of business and is specifically responsible for the resolution of Provider Payment Appeal requests
- Reviews and analyzes provider requests to investigate the outcome of a reconsideration
- Considers all information when determining whether to uphold or overturn primary decision
- Works with various departments including Provider Solutions and Health Plan Operations
Grievance/Appeals Analyst II OPW
Anthem
02.2018 - 12.2023
- Review, analyze, and process provider grievances and appeals in accordance with external and internal requirements and policies
- Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issues and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review
- Serve as a liaison between grievances and appeals and/or medical management, service operations and other internal departments
- Analyzes and renders determinations on assigned non-complex grievances and appeals issues as well as determinations on clinical grievances and appeals returned from nursing and/or MD’s
- Adjustment of claims upon approval and the completion of the respective written communication documents to convey the determination back to the providers
Claims Accumulator Adjuster OPW
Anthem
05.2015 - 02.2018
- Complete extensive research to accurately calculate member’s accumulators according to their specific benefit plan
- Duties also include completing audits on members to determine adjustments and updating systems to house correct data for members
- Adjust health claims in accordance with claims policies and procedures
- Including ITS claims
- Proficient use of LITES, WGS/STAR systems and ESI Website is needed to complete tasks such as Rx claims research, make any accumulator updates or adjusts as requested per Customer Care Reps, and resolve inquiries as needed
Utilization Management Representative-1
Anthem
11.2013 - 05.2015
- Determine contract and benefit eligibility through research and collaboration with outside departments
- Managing inbound and outbound calls as well as the tracking of inpatient admission, outpatient precertification, prior authorization and post service requests
- Conducting clinical screening process as well as checking benefits for facility-based treatment
- The identification and data entry of fax requests, member outreach, callouts, and predeterminations and entering the UM system in accordance with plan certificate
- Responding to telephone and written inquiries from clients, providers, and in house departments
Medical Insurance Representative
Southern Illinois University School of Medicine
03.2013 - 11.2013
- Responsible for collecting patient demographic, patient insurance information, all applicable billing information, and any other relevant data to be entered accurately into management systems
- Assisting patients in understanding all aspects of their benefits, access online systems to search databases for information regarding insurance information and online eligibility
- This position required strict confidentiality regarding patient information as well as time management and outreach to patients and payers
Customer Service Advocate in Provider Telecommunication Center
Blue Cross Blue Shield of Illinois
01.2005 - 01.2011
- Worked written inquiries submitted by physicians’ offices or hospitals
- Correcting claims per the provider request and submitting medical records to other BCBS companies
- Tracking records until resolved, & making follow ups until a resolution was provided
- Submitted patient records to the medical review unit for review by doctors and nurses to determine what claims to pay and researched pricing of codes that were unclassified in the system
- Verifying benefits and paid claims if beneficiary’s policy was with Blue Cross Blue Shield of Illinois
- Answering phones
- Setting up authorizations & constant prioritization and outreach to resolve issues
Eligibility Representative
HD Smith Drug Company
01.2002 - 01.2004
- Verified if customers were eligible for contract pricing per federal guidelines
- Once eligibility was confirmed, linked the customer to the contracts in the system
- Assisting the sales representatives and/or customers in resolving issues with contract pricing
- Analyzing data in spreadsheets and resolving any customer pricing errors related to contract pricing
Contracted Hotline Representative
Illinois Department of Public Aid
01.1998 - 01.1999
- Duties included giving providers eligibility information about patients KidCare and Medicaid coverage
- Sending new clients and their information to relevant programs and resolving issues for physicians and clients regarding all programs
- Answering phones and resolving issues for any incoming inquiries
Education
Completed College -
Lincoln Land Community college
Completed College -
Southwestern Illinois College
Skills
- Benefits
- Eligibility
- Claims
- Adjustments
- Accumulators
- Prescriptions
- Utilization
- Pre-authorization’s
- Predeterminations
- Provider Grievances and Appeals
- Clinical review processes
- Coordination of benefits
- Medicare benefits & claims
- BlueCard home & host
- Customer service
References
Available upon request.
Timeline
Provider Payment Appeal Analyst II OPW
Anthem
01.2024 - Current
Grievance/Appeals Analyst II OPW
Anthem
02.2018 - 12.2023
Claims Accumulator Adjuster OPW
Anthem
05.2015 - 02.2018
Utilization Management Representative-1
Anthem
11.2013 - 05.2015
Medical Insurance Representative
Southern Illinois University School of Medicine
03.2013 - 11.2013
Customer Service Advocate in Provider Telecommunication Center
Blue Cross Blue Shield of Illinois
01.2005 - 01.2011
Eligibility Representative
HD Smith Drug Company
01.2002 - 01.2004
Contracted Hotline Representative
Illinois Department of Public Aid
01.1998 - 01.1999
Completed College -
Lincoln Land Community college
Completed College -
Southwestern Illinois College
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