Jessica Tuggle
Houston,Texas
Summary
Experienced Leader in Healthcare Compliance Analyst with 8+ years of experience supporting regulatory compliance, Appeals & Grievances (A&G), quality assurance, and operational risk mitigation within managed care and hospital systems. Demonstrated expertise in CMS- and state-regulated complaint resolution, audit readiness, HIPAA privacy standards, and root cause analysis. Adept at translating regulatory requirements into clear documentation, corrective actions, and compliant outcomes across cross‑functional teams. Results-oriented specialist with expertise in data analysis, regulatory compliance, and problem-solving. Proven track record in enhancing healthcare processes and member satisfaction through effective communication and continuous improvement.
Overview
10
10
years of professional experience
Work History
Lead Appeals and Grievances Specialist/Coordinator
Molina Healthcare
Houston, Texas
09.2021 - 02.2026
- Oversaw submission, intervention, and resolution of appeals, grievances, and complaints from Molina members and outside agencies, ensuring timely responses.
- Research issues using systems and clinical assessment skills, knowledge and approved 'Decision Support Tools' in the decision-making process on health care services and care provided to members.
- Coordinated Molina’s Concierge Pilot Program, screening frequent callers’ complaints and organizing member calls and concerns into pivot tables for weekly meetings.
- Utilize CVS Caremark for pharmacy related claim inquiries regarding Prior Authorization and claim status.
- Analyzed data trends to inform strategic decision-making, enhancing responsiveness to member needs.
- Developed reports to summarize findings and present insights to stakeholders.
- Monitored key performance indicators to ensure alignment with organizational goals.
Community Health Worker -Sunnyside Community Center
C.H.E.F. Fellowship Program
Houston, Texas
08.2020 - 10.2020
- Work with members to find barriers to accessing care and achieving person-centered goals, as well as work to close gaps in care.
- Work with members to develop healthcare goals and find potential barriers.
- Assisted patients in completing applications for Medical Assistance and SNAP to improve access to essential resources.
- Assisted individuals in accessing social services and healthcare programs.
- Informed community members about health resources and preventive care practices to support informed health decisions.
- Partnered with local organizations to enhance community health awareness and engagement.
- Functioned as a community resource at City of Houston, enhancing public health initiatives.
- Provided cultural competency training to improve service delivery among staff.
- Works to create linkages with agencies already providing services in the community for students and families.
- Gathered data on community health needs through surveys and interviews.
- Provided community service referrals for individual patients.
Revenue Cycle Specialist II
UT Health and Science Center
Houston, Texas
10.2019 - 05.2020
- Met all productivity and collection goals including dollars collected and accounts handled.
- Implemented process improvements that streamlined claims handling, reducing turnaround time and enhancing workflow efficiency.
- Collaborated with practice leaders, providers, and residents to clarify billing issues, ensuring timely resolution and accurate payments.
- Initiated appeals of denial of payment for services.
- Attained referrals and authorizations for inpatient and outpatient services.
- Analyzed account receivables, resolving discrepancies to enhance collection accuracy.
- Analyzed claims data to identify discrepancies and improve processing accuracy.
- Reviewed policy documentation to ensure compliance with company standards and regulations.
Patient Access Representative II – Insurance Verifier II
TIRR Memorial Hermann
Houston, Texas
12.2017 - 06.2019
- Processed authorizations and confirmed insurance coverage via fax, phone, and online systems to facilitate patient access.
- Experience with Medicare, Medicaid, PPOs, HMOs, and Marketplace Insurances.
- Obtaining Outpatient Physical, Occupational, and Speech Therapy Authorization for assigned TIRR Rehabilitation locations.
- Coordinated authorization requests among departments and external stakeholders to streamline workflow.
- Collaborated with healthcare providers to resolve authorization issues promptly.
- Ensured timely communication of authorization decisions to relevant parties, enhancing patient care efficiency.
- Increased accuracy audits by 25% at assigned locations.
- Contributed to operations at Memorial Hermann Health Systems, focusing on authorization processes.
- Creating new accounts within Health Quest for billing to process efficiently.
Director of Parent Billing/Lead Medical Biller
Tangible Difference Learning Center
Houston, TX
04.2016 - 03.2017
- Billed Claims to UHC, BCBS, Humana, Cigna, and Tricare for all 3 associated facilities.
- Checked insurance eligibility for each child under assigned plans.
- Posted Payments for appointed insurance companies through Leonardo MD.
- Retrieved Medical/Behavioral Authorizations for appointed Insurance companies.
- Directed 3 colleagues in billing processes, enhancing team efficiency and service quality.
- Used QuickBooks for calculating deductibles, co-insurances, copays to generate statements for parents.
- Follow up with parent emails and phone calls regarding concerns about billing statements.
- Coordinated bi-weekly medical billing meetings to analyze revenue projections and strategize improvements.
- Implemented service enhancements at Autism Center for Children, contributing to improved client outcomes.
Education
B.A. - Healthcare Administration
University of Houston Downtown
05-2026
Community Health Worker -
Lone Star College
10.2020
Medical Insurance Billing and Coding (Certificate) -
Everest Institute
04.2013
H.S. Diploma -
Bellaire Senior High School
06.2011
Skills
- Medical Terminology
- Typing 85 WPM
- Interpersonal Skills
- Insurance Verification
- Microsoft Office Proficient
- Legal and Ethical Guidelines
- HIPAA Compliant
- CPT Procedure Coding
- Revenue Management
- Computer Billing Systems
- Claims Process
- Bill Collection Strategies
- Electronic Data Storage
- Medical Records Analyst
- Data analysis
- Effective communication
- Regulatory compliance
- Continuous improvement
- Expert problem solving
- Quality assurance
- Analytical thinking
- Task prioritization
- Microsoft Excel
- Healthcare compliance
- Compliance monitoring
- Interpersonal skills
Timeline
Lead Appeals and Grievances Specialist/Coordinator
Molina Healthcare
09.2021 - 02.2026
Community Health Worker -Sunnyside Community Center
C.H.E.F. Fellowship Program
08.2020 - 10.2020
Revenue Cycle Specialist II
UT Health and Science Center
10.2019 - 05.2020
Patient Access Representative II – Insurance Verifier II
TIRR Memorial Hermann
12.2017 - 06.2019
Director of Parent Billing/Lead Medical Biller
Tangible Difference Learning Center
04.2016 - 03.2017
B.A. - Healthcare Administration
University of Houston Downtown
Community Health Worker -
Lone Star College
Medical Insurance Billing and Coding (Certificate) -
Everest Institute
H.S. Diploma -
Bellaire Senior High School