Janell M. Coleman
Kaiser Foundation Health Plan
Social Circle,GA
1
Language
23
years of professional experience
Detail-oriented and analytical healthcare operations professional with extensive experience in quality auditing, provider reimbursement, claims review, and appeals. Proven ability to manage complex workloads, meet strict deadlines, collaborate across diverse teams, and maintain professionalism under pressure. Recognized for strong problem-solving skills, creativity, and the ability to work effectively with diverse populations.
Work History
Claims Auditing Specialist III
11 Years 3 Months- Determine covered medical insurance loss or overpayment by analyzing provider contract provisions.
- Evaluate risks related to requirements and implementation testing to reduce financial errors.
- Analyze benefit configuration to ensure correct coverage for services rendered.
- Conduct quality assurance audits for cases, adjustments, refunds, and provider disputes to ensure accurate data entry and claim payments.
- Perform complex and routine audits on provider contracts, remittance systems, and claim payments.
- Monitor and evaluate provider contract updates used by quality staff.
- Ensure consistent adherence to quality and compliance procedures.
- Professional experience using SMS and chat-based communication tools.
Provider Reimbursement Specialist
7 Years 1 Month- Reviewed and audited medical claims submitted by non-plan providers for accuracy and appropriateness.
- Consulted with clinical staff to determine medical necessity of procedures or care.
- Responded to provider appeals and validated whether billed services matched care provided.
- Reviewed CPT/ICD-9 coding for appropriateness and identified contracting opportunities to reduce erroneous billing.
- Assisted in identifying fraudulent billing practices and supported litigation preparation with legal teams.
- Prepared periodic reports to support quality initiatives.
- Developed training materials to improve claims medical review processes.
- Provided inbound call support as needed.
Senior Case Manager
1 Year- Managed grievance and appeals review processes, including investigation, preparation, and presentation of case materials.
- Partnered with internal/external departments and medical groups to resolve member concerns.
- Maintained case databases and ensured timely resolution in compliance with federal and state regulations.
Provider Reimbursement Specialist
4 Years- Responded to provider appeals and evaluated medical interventions against billed charges.
- Collaborated with RN clinical review staff to assess coding and charge levels.
- Identified contracting opportunities to reduce billing errors and control outside medical costs.
- Ensured timely and appropriate handling of provider disputes.
- Assisted in identifying fraudulent billing practices and supported legal preparation.
- Trained new employees on reimbursement processes and procedures.
Education
Business Major
Skills
Quality Auditing & Compliance
Claims Review & Reimbursement
Provider Appeals & Dispute Resolution
CPT/ICD Coding Review
Fraud Detection & Investigation Support
Contract Interpretation & Benefit Configuration
Cross-Functional Collaboration
Training & Process Improvement
Case Management
Reporting & Data Accuracy
Accomplishments
I have received several People Matter I matter awards.
Languages
English
Full Professional
Timeline
Claims Auditing Specialist III
Kaiser Foundation Health Plan
05.2015 - CurrentRead More
Provider Reimbursement Specialist
Kaiser Foundation Health Plan
04.2008 - 05.2015Read More
Senior Case Manager
Kaiser Foundation Health Plan
04.2007 - 04.2008Read More
Provider Reimbursement Specialist
Kaiser Foundation Health Plan
04.2003 - 04.2007Read More
Heald Business College
Business Major
Read More