Jackesha Whittle
Louisville,KY
Summary
Healthcare claims and provider services professional with experience in claims adjudication, prior authorization, and reimbursement support. Uses data analysis, reporting, and process review to identify trends, improve accuracy, and support efficient claims operations. Also trains new staff and tracks healthcare regulations affecting submissions.
Overview
1
1
Certification
10
10
years of professional experience
Work History
Provider Services Analyst/Claims Educator
United Health Group, Optum
Indianapolis, IN
03.2024 - Current
- Examined claim trends to support process improvements and efficiency gains.
- Drove process improvement and efficiency gains through claim trend analysis.
- Reviewed data to identify trends, discrepancies, and improvement opportunities across healthcare systems.
- Identified data trends, discrepancies, and improvement opportunities across healthcare systems.
- Created reports and presentations from health data analysis to enhance decision-making processes.
- Supported informed decision-making with reports and presentations developed from health data analysis.
- Built reports and presentations from health data analysis to inform decision-making.
- Compiled industry trend reports and delivered findings to assist managers in formulating business plans.
- Delivered industry trend reports that guided managers in developing business plans.
- Raised awareness of current healthcare information management trends through conference and meeting presentations.
- Presented healthcare information management findings during conferences and meetings to raise awareness of current industry trends.
- Expanded understanding of current healthcare information management trends through conference and meeting presentations.
- Facilitated training for new staff on claims processing procedures and system functionality.
- Trained new staff on claims processing protocols and system functionality.
- Improved new staff readiness by assisting with claims processing protocols and system training.
- Maintained current knowledge of healthcare regulations relevant to claims submissions.
- Kept current on healthcare regulations affecting claims submissions.
- Developed expertise in Facets, SQL, and CoreMMIS over three years.
- Drove process improvement and efficiency gains through claim trend analysis.
- Improved new staff readiness by assisting with claims processing protocols and system training.
- Kept current with healthcare regulations relevant to claims submissions.
- Developed expertise in Facets, SQL, and CoreMMIS over three years.
Claims Adjudicator
Molina Healthcare
Louisville, KY
11.2022 - 01.2024
- Reviewed claim documentation for coding, eligibility, and authorization accuracy.
- Investigated escalated claims issues to ensure timely and accurate resolutions.
- Collaborated with internal departments to resolve complex claim issues effectively.
- Analyze claims adjudication data for trends and patterns to improve accuracy and efficiency.
- Identified and analyzed cost-saving opportunities within claims adjudication workflows.
- Work with policyholders and healthcare providers to collect needed information for claim resolution.
- Reprocessed claims to ensure accuracy and compliance with company standards.
Prior Authorization Coordinator
Bright Health Springs
Louisville, KY
04.2021 - 10.2022
- Coordinate with healthcare providers and insurance carriers to process prior authorization requests quickly and reduce care delays.
- Assisted in streamlining prior authorization workflows, facilitating timely approval of medical services.
- Coordinated with healthcare providers to gather required medical information for prior authorization requests, maintaining comprehensive documentation.
- Supported insurance appeals following prior authorization denials, ensuring thorough documentation and timely follow-up.
- Assist with training healthcare providers on prior authorization submission requirements for accurate, complete requests.
- Support quality checks for prior authorization documentation accuracy and completeness.
- Verified Medicaid and Medicare coverage details for patients.
- Review patient information for medical and pharmaceutical authorizations.
Provider Claims Representative
Evolent Health
Louisville, KY
10.2018 - 05.2021
- Review provider claims for accuracy, investigate fraud indicators, and support prompt claim payment.
- Cultivated strong provider relationships, facilitating smooth claims processing and timely reimbursement.
- Analyzed claims data to identify billing patterns, recommending solutions to enhance accuracy and streamline workflow.
- Update claims processes to align with industry standards and regulatory requirements.
- Trained and supported healthcare providers on claims submission procedures, ensuring adherence to guidelines.
- Submitted prior authorization requests to the utilization management department for thorough review.
- Verified receipt of prior authorization requests to ensure timely processing.
- Handled inbound calls while adhering to Medicaid and Medicare guidelines for compliance.
Reimbursement Case Manager II
Omnicare, a CVS Health company
Louisville, KY
06.2016 - 09.2018
- Negotiate payment terms and contracts with third-party payers to ensure maximum reimbursement for customers' medications while maintaining a positive business relationship
- Developed and maintained relationships with third-party payers, optimizing reimbursement for customer medications and health insurance
- Managed and resolved issues with inaccurate or delayed reimbursements from third-party payers, ensuring timely payments for customers
- Verify patient coverage and communicate with medical facilities to resolve discrepancies regarding the prior authorization
- Educated healthcare providers on reimbursement processes and requirements for medications, enhancing their understanding and compliance
- Submitted pre-authorizations to insurance companies and provider offices
- Verified accuracy of patient account information
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
Some College (No Degree) - Project Management
DeVry University
Chicago, IL09-2026
Skills
- Claims management
- Prior Authorization
- Data analysis
- Trend Analysis
- Claims Investigation
- Project management
- Healthcare
- Pharmaceutical Industry
- Microsoft Word
- Management
- Team leadership
- Customer Service
- Decision-Making
- Interpersonal Communication
Accomplishments
- Customer advocate of The Day Award
- Top QA Performance
- Kudos Award
- Wilma Dorm Vice President
Certification
KY Pharmacy Board License
Timeline
Provider Services Analyst/Claims Educator
United Health Group, Optum
03.2024 - Current
Claims Adjudicator
Molina Healthcare
11.2022 - 01.2024
Prior Authorization Coordinator
Bright Health Springs
04.2021 - 10.2022
Provider Claims Representative
Evolent Health
10.2018 - 05.2021
Reimbursement Case Manager II
Omnicare, a CVS Health company
06.2016 - 09.2018
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
Some College (No Degree) - Project Management
DeVry University