Felicia Yelverton-Abel
York,PA
Summary
Experienced health insurance professional successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Willingness to take on any challenges and added responsibilities to meet and exceed team goals.
Overview
26
26
years of professional experience
Work History
Senior Appeals Specialist
Independence Blue Cross
11.2018 - Current
- Act as departmental resource on appeals matters.
- Conducted comprehensive training sessions for new hires on proper procedures for processing claims denials and managing appeals caseloads.
- Investigates and researches member and provider appeals and complaints in accordance with established policies. Responsible to serve as customer's advocate and respond to all inquiries and complaints concerning appeal or grievance.
- Communicates effectively and professionally with internal departments and external resources to coordinate and investigate information as it relates to complaint. Ensure that all plan exceptions and overturns are effectuated timely and in compliance with Department of Labor Appeals department guidelines.
- Ensure case file documents are filed and secured according to unit guidelines and are submitted timely for QA purposes. Organize case files as needed for external review per regulatory guidelines.
Network Service Analyst
Independence Blue Cross
10.2005 - 11.2018
- Responsible for handing appeals from local participating providers for continued inpatient services that have been denied as not medically necessary and reduced level of care, within departmental and corporate standard guidelines. Accurately responds to frequent calls from hospitals, appeal agencies & physicians with questions on status and appeal process. Contact Medical Directors with any discrepancies discovered during the concurrent review of inpatient admission.
- Create determination letter with outcome of appeals and forward to contacts at appealing hospital. Update authorization in Utilization Management system if appeal is overturned.
- Solely responsible for Federal Employee Program appeals received electronically from both professional providers and hospital services for medical necessity denials.
- Streamlined appeal processes for increased production and efficiency.
Claims Entry Examiner
AmeriHealth Adminstrators
04.2001 - 10.2005
- Contributed positively to organizational reputation by consistently demonstrating professionalism, integrity, and expertise in role of Examiner.
- Responsible for reviewing researching and finalization legibility and provider information for electronic and paper claims.
- Responsible for provider service support to claims and provider maintenance department for claim payment.
Claims Service Representative
AmeriHealth Administrators
06.1998 - 03.2001
- Provided exceptional customer service by addressing concerns, answering questions, and explaining complex policy information to clients.
- Repriced claims through various networks utilized multiple systems to obtain and record claims information to make claim payment decision.
- Transferred priced claims to be adjudicated by claims examiner. Maintained and updated provider billing information and network affiliations. Processed facility claims and provided support as needed by client.
Education
Associate of Applied Science - Health Information Technology
DeVry University
03.2013
Skills
- Strong analytical skills
- Organizational abilities
- Professionalism and Ethics
- Insurance Policies Understanding
- Appeals Process Proficiency
- Task Prioritization
- Multitasking Abilities
- Attention to Detail
- Teamwork and Collaboration
- Continuous learning mindset
- Lean Six Sigma Optimization Project for process improvement
Additional Information
Proficient in the use of most major computer systems, spreadsheet applications, presentation applications, and word processing applications, including but not limited to Microsoft Word, PowerPoint, Excel, and Internet Explorer. Executes multiple formal processes of training to the new employees to include appeals process and grievances. Auditing new employee determinations before member/provider notification of appeal outcome.
Timeline
Senior Appeals Specialist
Independence Blue Cross
11.2018 - Current
Network Service Analyst
Independence Blue Cross
10.2005 - 11.2018
Claims Entry Examiner
AmeriHealth Adminstrators
04.2001 - 10.2005
Claims Service Representative
AmeriHealth Administrators
06.1998 - 03.2001
Associate of Applied Science - Health Information Technology
DeVry University
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