Jackesha Whittle
New Albany,United States
Summary
Dedicated team player adept at managing customer service and claims processing for policyholders. Looking for a long-term position with a growth-oriented company.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Provider Services Analyst
United Health Group, Optum
Indianapolis, IN
03.2024 - Current
- Presented findings at conferences or meetings regarding current trends in healthcare information management.
- Developed reports and presentations based on findings from health data analysis.
- Conducted research studies using various sources of health-related information such as surveys, medical records.
- Collaborated with other healthcare professionals to develop strategies for improving patient care quality and outcomes.
- Conducted periodic reviews of supplier agreements to ensure accuracy of information and compliance with regulations.
- Coordinated with providers, payers, and other third parties as necessary.
- Developed relationships with new providers by providing guidance on how to use our systems, processes, and policies.
- Responded promptly to emails sent by providers concerning billing inquiries or other related matters.
Claims Adjudicator
Molina Healthcare
Louisville, KY
12.2022 - 01.2024
- Collaborate with internal departments to analyze and resolve complex claim issues
- Conduct regular audits of claims adjudication processes to ensure compliance with regulatory requirements and internal policies
- Investigate and resolve escalated claims issues in a timely and accurate manner
- Identify trends and patterns in claim data to proactively detect potential fraud and abuse
- Identify trends and patterns in claims adjudication data to improve accuracy and efficiency
- Identify opportunities for cost reduction in claims adjudication process
- Collaborate with policyholders and healthcare providers to gather necessary information for claim resolution
- Conduct Appeal Status
- Submitting prior authorizations to the providers office for approval.
Prior Authorization Coordinator
Bright Health Springs
Louisville, KY
05.2021 - 11.2022
- Appeal insurance companies after prior authorization refusals
- Implement and maintain an efficient and accurate prior authorization process to ensure timely approval of medical services
- Coordinate with healthcare providers and insurance companies to ensure timely and accurate processing of prior authorization requests, maximizing efficiency and minimizing delays in patient care
- Collaborate with healthcare providers to obtain necessary medical information for the prior authorization process and ensure accurate and complete documentation
- Develop and implement training programs for healthcare providers on the prior authorization process to ensure accurate and complete submission of requests
- Develop and implement quality assurance measures to ensure the accuracy and completeness of prior authorization documentation
- Medicaid/Medicare Verification
- Verification of Patient information for medical/pharmaceutical authorizations.
Provider Claims Representative
Evolent Health
Louisville, KY
10.2018 - 05.2021
- Conduct thorough investigations to determine the validity of provider claims and identify any potential fraudulent activities, ensuring accurate and timely payment of claims
- Develop and maintain relationships with healthcare providers to ensure smooth claims processing and timely payments
- Analyze provider claims data to identify patterns and trends in billing practices, and recommend strategies to reduce claim errors and improve efficiency
- Evaluate and update provider claims processes to align with industry standards and ensure compliance with regulatory requirements
- Provide training and support to healthcare providers on the claims submission process and guidelines
- Submitting prior authorization to the UM dept for further review
- Verifying Prior authorization has been received
- Following Medicaid/Medicare Guidelines.
Reimbursement Case Manager II
Omnicare, a CVS Health company
Louisville, KY
07.2016 - 10.2018
- Develop and maintain strong relationships with third-party payers to optimize reimbursement for customers' medications/health insurance
- Provide education to healthcare providers on reimbursement processes and requirements for medications
- Negotiate payment terms and contracts with third-party payers to ensure maximum reimbursement for customers' medications while maintaining a positive business relationship
- Manage and resolve any issues related to inaccurate or delayed reimbursements from third-party payers
- Verify patient coverage and communicate with medical facilities to resolve and discrepancies regarding the prior authorization
- Verify patient account information is accurate
- Submitting pre-authorizations to the insurance company/Provider office.
Business Development Consultant
Louisville Chrysler Dodge Jeep Ram
Louisville, KY
01.2016 - 07.2016
- Identify potential business opportunities in the market and develop strategies to capitalize on them
- Conduct market research to identify potential business opportunities and develop strategies to capitalize on them
- Analyze customer feedback and market data to identify customer needs and preferences, and develop strategies to meet those needs
- Establish and maintain relationships with key decision-makers in the market to identify potential business opportunities and develop strategies to capitalize on them
- Develop innovative solutions to address customer needs and differentiate the company from competitors.
Education
Associates - Medical Billing And Coding
Ata College
Louisville03.2025
Associates - Healthcare Administration
Indiana Tech
Louisville07-2018
High School Diploma -
Muhlenberg Career Development Center
Greenville04.2013
Medical Office Support - Health Administration
Muhlenberg Career Development Center
Greenville, KY04.2013
Skills
- Management
- Customer Service
- Healthcare
- Pharmaceutical Industry
- Data Entry
- Microsoft Office
- Microsoft Word
- Multi Line Phone
- Call Center Development
- Healthcare Reimbursement
- Prior Authorization
- Analytical Skills
- Claims Investigation
- Decision-Making
- Interpersonal Communication
- Team collaboration and leadership
- Evidence-based decision making
Accomplishments
- Customer advocate of The Day Award
- Top QA Performance
- Kudos Award
- Wilma Dorm Vice President
Certification
KY Pharmacy Board License
Education and Training
other,true
Languages
English
Timeline
Provider Services Analyst
United Health Group, Optum
03.2024 - Current
Claims Adjudicator
Molina Healthcare
12.2022 - 01.2024
Prior Authorization Coordinator
Bright Health Springs
05.2021 - 11.2022
Provider Claims Representative
Evolent Health
10.2018 - 05.2021
Reimbursement Case Manager II
Omnicare, a CVS Health company
07.2016 - 10.2018
Business Development Consultant
Louisville Chrysler Dodge Jeep Ram
01.2016 - 07.2016
Associates - Medical Billing And Coding
Ata College
Associates - Healthcare Administration
Indiana Tech
High School Diploma -
Muhlenberg Career Development Center
Medical Office Support - Health Administration
Muhlenberg Career Development Center
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