ANTOINETTE DANIELS
Philadelphia,PA
Summary
Experienced healthcare operations and provider relations professional with over 20 years in workers' compensation and health plan operations. Expertise includes medical claims review, coding validation, and billing research. Foster interdepartmental collaboration to ensure compliance and enhance operational efficiency.
Overview
21
21
years of professional experience
Work History
Provider Relations Specialist / Bill Repricer
INDEPENDENCE BLUE CROSS / AMERIHEALTH CASUALTY
01.2020 - Current
- Audited TPA/Managed Care commercial healthcare claims against supporting documentation, validating CPT/HCPCS and diagnosis codes to ensure compliance and accuracy.
- Review and audit TPA/Managed Care commercial healthcare against supporting documentation, validating CPT/HCPCS and Diagnosis Codes.
- Analyze medical records and operative reports to validate clinical documentation and support accurate claim processing and reimbursement.
- Researched coding discrepancies, pricing adjustments, billing questions, and claim errors to facilitate timely resolutions and enhance claim integrity.
- Respond to provider inquiries about participation, contracts, billing, reimbursement, and network information.
- Coordinated medical bill repricing and fee schedule reviews by investigating discrepancies and collaborating with internal teams to optimize reimbursement processes.
- Coordinate provider contract documentation, amendments, and Single Case Agreements (SCAs), maintaining accurate supporting records.
- Use multiple claims, coding, and enterprise systems to review, document, track, and process work accurately and efficiently.
- Maintain audit-ready records and follow HIPAA and applicable confidentiality requirements while supporting quality and process-improvement initiatives.
Senior Provider Relations Specialist
INDEPENDENCE BLUE CROSS / AMERIHEALTH CASUALTY
01.2006 - 01.2020
- Managed relationships with healthcare providers, resolving claims issues, billing discrepancies, coding questions, and contract-related inquiries.
- Explained claims procedures, coding requirements, policies, and system updates to provider offices to support accurate submissions and reduce repeat inquiries.
- Coordinated with claims, coding, finance, and contracting teams to research and resolve provider issues within established service expectations.
- Reviewed claims and provider information to identify trends, support operational decisions, and recommend improvements to provider service and billing workflows.
- Maintained accurate provider documentation in accordance with HIPAA requirements and applicable state and federal guidelines.
- Served as a resource for provider questions involving claims processing, coding requirements, and contract terms.
- Identified recurring provider inquiries and processing issues and recommended practical workflow improvements.
- Coordinated relationships with over 5000+ healthcare providers, ensuring up-to-date credentials and licensing.
- Create, edit and design workers’ compensation panels, based on individual client’s specifications.
- Establish and maintain profiles for both new and current providers.
- Verify and update all demographic information regarding all medical providers within AmeriHealth’s database.
Education
High School Diploma -
Overbrook High School
Philadelphia, PASkills
- Provider relations
- Claims processing
- Claims Dispute Resolution
- Medical Bill Repricing
- Reimbursement review
- Coding validation
- Claims Analysis
- Discrepancy resolution
- Contract management
Timeline
Provider Relations Specialist / Bill Repricer
INDEPENDENCE BLUE CROSS / AMERIHEALTH CASUALTY
01.2020 - Current
Senior Provider Relations Specialist
INDEPENDENCE BLUE CROSS / AMERIHEALTH CASUALTY
01.2006 - 01.2020
High School Diploma -
Overbrook High School