JESSICA HOLLOWAY
ATLANTA,GA
Summary
Dedicated, results-oriented Professional with 15+ years of total experience in clinical, healthcare compliance, and customer service. Proven capability to interact and negotiate with clients, collaborate in team settings, and provide subject matter expertise. Success in achieving multiple objectives in high-volume, high-pressure and remote environments while adhering to relevant policies and procedures.
Overview
15
15
years of professional experience
Work History
Clinical Correspondence Writer/Editor
Healthfirst
01.2023 - Current
- Responsible for generating written medical management determination letters across all of, 's managed care products as well as copy edit and proofread all external communication pieces, ensuring correct grammatical usage, punctuation and syntax
- Promotes compliance with policy and regulatory requirements related to the Medical Management Department letters
- Utilize critical thinking skills, job-specific policies and terminology, clinical and managed care knowledge, to review and audit Medical Management letters
- Independently accurately audit, compose/generate a wide variety of organizational determination letters to enrollees, providers and facilities including initial determination, fair hearing and detailed letters of denial across all product lines
- Collaboration with care managers, the management team and peer reviewers to comply with regulatory-mandated notices and analyze/audit letters for appropriate medical terminology while using across department policies and federal and state regulations governing organizational determinations
- Perform daily reviews of manual letters produced from CCMS to member and providers to ensure adherence to Article 44 and 49 of the NY State Public Health Law and Appendix F, Medicare Managed Care Manual Chapter 13 and commercial contracts and others as necessary
- Ensure compliance with Healthfirst corporate branding requirements
- Conduct quality checks of CCMS event while reviewing letters to ensure compliance to all managed care regulations while identifying and documenting areas of non-compliance.
APPEALS COORDINATOR
PEACH STATE HEALTH PLAN DENIALS
08.2017 - Current
- Evaluate claim grievance for reconsideration and approve or deny based on determination level
- Investigate if claim grievance includes potential quality or access issue and prepare cases for medical review as necessary
- Resolve all State inquires by acting as subject expert regarding grievances and appeals provider regulatory agencies, and internal staff
- Coordinate with key individuals and specialists, utilizing advanced interpretations to resolve complex cases
- Analyze and resolve verbal and written claims and authorization grievance and appeals from providers and members
- Liaison between member, provider regulatory agencies, and internal staff
- Review and process member and provider grievances and appeals within federal, state and organizational regulations and policies and procedures.
Grievance Specialist
Molina Healthcare Appeals
05.2022 - 01.2023
- Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met
- Research claims appeals and grievances using support systems to determine appeal and grievance outcomes
- Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines
- Responsible for meeting production standards set by the department
- Apply contract language, benefits, and review of covered services
- Responsible for contacting the member/provider through written and verbal communication
- Prepares appeal summaries, correspondence, and document findings
- Include information on trends if requested
- Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements
- Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error
- Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies.
ASSOCIATE II MEMBER SERVICES
Kaiser Permanente
09.2014 - 08.2017
- Professionally interfaced with callers, providing quality assistance and resolution
- Oversaw difficult callers with compassion and patience, while escalating when necessary
- Served as claims payment expert, explaining information on receipts, eligibility, benefits, delivery system services, payment quantities, deadlines, and authorization status
- Remained updated on claims processing guidelines and health plan benefits by studying literature, staying aware of trends, and participating in workshops
- Conducted research for root cause analysis and reporting trends
- Interacted, collaborated, and negotiated across all organizational levels
- Attended meetings to enhance departmental performance
- Recorded phone calls and collected data
- Applied various statistical techniques to analyze individual and call center performance, independently providing recommendations for process improvement and service recovery
- Supported internal customers with special projects and studies to optimize service
- Mastered knowledge of relevant medical terminology, CPT, and ICD-9 coding.
APPEALS COORDINATOR
United Health Care
01.2012 - 12.2013
- Provided expertise or general claims support by reviewing, negotiating, and adjusting claims
- Responded to provider phone calls and correspondences, including claim adjustment requests, appeals, corrected claims, timely filings, and claims projects
- Managed complex clinical appeals such as transplants
- Researched, collaborated, and triaged all types of appeals and grievances
- Identified and analyzed trends, overseeing coordination and collection of all information and presentation to Medical Director/Appeals Committee
- Evaluated and approved member eligibility and benefits by investigating member information such as authorizations, payments, denials, and coordination of benefits
- Collected case review documentation, analyzing if physician review is required and preparing written responses
- Coordinated outside physician clinical reviews, including with Health Services to obtain clinical information
- Documented receipt of appeals and conducted timeline tracking to ensure responses within timeframe
- Prioritized tasks to consistently adhere to HIPAA regulations, Georgia Medicaid and Medicare regulations, and industry standards for claims adjudication
- Mastered knowledge concerning UHC benefits, provider network development and contract issues, and other party liability issues
- Familiarized with CPT-4, ICD9, and HCPCS coding.
FRONT DESK COORDINATOR
Peachtree Orthopedics
02.2011 - 12.2012
- Greeted patients and visitors in prompt, courteous, and helpful manner
- Answered incoming calls, maintained waiting area, screened visitors, and provided routing request information
- Checked in patients, verified and updated information, and reported issues to Registration Coordinator
- Assisted patients with ambulatory difficulties
- Prepared patient electronic-charts with “new patient” documentation and updated information for “established patients.” Gathered workers' compensation information and appropriate forms, monitoring and reporting unscanned or missing intake forms
- Handled patient checkout, collected copays, and reconciled daily receivables
- Documented daily collection sheet of copays and totals cash, checks, credit cards
- Updated physician schedules and scheduled patient appointments
- Supported front desk, medical assistants, physician assistants, and other staff with miscellaneous task.
Education
Clayton State University
Skills
- Medical Billing & Coding Regulations Compliance Verbal & Written Expertise
- Communication & Client Interface Documentation & Assessment Coordination & Teamwork Planning & Organization
- Remote Experience
- Administrative Support & Customer Service
- Clinical Writer
- Denials, Appeals, & Claims ICD-10 Coding
- Accounting Principles Auditor
Timeline
Clinical Correspondence Writer/Editor
Healthfirst
01.2023 - Current
Grievance Specialist
Molina Healthcare Appeals
05.2022 - 01.2023
APPEALS COORDINATOR
PEACH STATE HEALTH PLAN DENIALS
08.2017 - Current
ASSOCIATE II MEMBER SERVICES
Kaiser Permanente
09.2014 - 08.2017
APPEALS COORDINATOR
United Health Care
01.2012 - 12.2013
FRONT DESK COORDINATOR
Peachtree Orthopedics
02.2011 - 12.2012
Clayton State University