KaShauna V. Woodson
Wilmington,USA
Summary
Insurance professional seeking to obtain a challenging position, which will allow me to utilize my technical knowledge, while developing new professional experience. Over 18 years of relevant work experience with a proven ability to effectively plan and implement, gather, and analyze data, document key decisions and findings, and communicate pertinent information to all levels of professionals, as well as clients.
Efficient Health Insurance Specialist known for productivity and effectiveness in task completion. Possess specialized skills in policy analysis, claims processing, and regulatory compliance which facilitate smooth operations. Excel at communication, problem-solving, and adaptability, ensuring seamless coordination within teams and with clients.
Overview
14
14
years of professional experience
2027
2027
years of post-secondary education
Work History
Health Insurance Specialist
Provider Resources
Erie, USA
02.2023 - Current
- Applies critical thinking skills, IDRE (Independent Dispute Resolution) program policies and regulatory guidance to analyze and adjudicate payment determination disputes involving non-participating providers, non-participating emergency facilities, and group health plans.
- Reviews documentation submitted by all parties, assesses proposed payment amounts, and renders independent determinations by selecting one of the two offers based on the credible facts presented.
- Completes case related documentation, sending notifications per workflow requirements, and ensuring accurate and timely data entry into the government portal.
- Communicates professionally with government and private-sector clients, partners, and internal stakeholders.
- Builds collaborative relationships through proactive, clear, and expectation-setting communication.
- Manages and coordinates activities to ensure timely delivery of all contract obligations.
- Collaborates with project team members to meet quality requirements.
- Supports business development initiatives through professional interactions and consistent delivery of high-quality work.
- Conducts research and reference verification using project resources.
- Handles a high-volume workload with varying deadlines.
- Demonstrates flexibility and adaptability to meet contract performance metrics.
- Submits accurate, timely deliverables and maintain excellent customer service standards.
- Perform other related duties as assigned.
Sr. Billing Analyst Dental & Vision
AFLAC
Tampa, USA
03.2022 - 02.2023
- Performed billing analysis and reporting on customer behavior and products to provide predictive analytics that can be leveraged in improving revenue, payment timing, and customer retention via CHIPS System.
- Analyzed and generated monthly standardized and ad-hoc reporting via Aldera and EIS Systems to provide leadership with status, delinquency, and average billing and payment information.
- Utilized financial reports to ensure compliance with regulated or contracted guidelines; tracked and resolved billing discrepancies and issues; developed root cause analysis of issues and developed solutions to remedy reoccurring problems; conducted GAP analysis revenues received versus issued as well as short- and long-term trends and impacts.
- Worked on special projects/process improvements; serves as a subject matter expert on projects that will create or improve the combined billing functionality, usage, or strategy; coordinates activities and initiatives with other divisions, associates, and business stakeholders; assisted in developing and conducting training or awareness processes for the field regarding process implementation.
- Analyzed and corrected group set up, as needed; ensured group billing accounts are set up correctly and according to Aldera and EIS requirements.
- Analyzed all billing processes and data, troubleshooted issues as they came; analyzed all billing procedures and identified opportunities for improvement.
- Executed tasks according to the monthly billing cadence; verified, issue and send accurate invoices timely.
- Reconciled in-force premium to production credit systems and facilitate necessary changes.
- Communicated with clients and other departments, resolving issues, and providing clarifications.
- Executed monthly reconciliations.
- Presented monthly reports on performance; developed and presented decision-making matters to key management team.
Sr. Billing Specialist
The Hartford Insurance
Hartford, USA
07.2019 - 03.2022
- Managed complex and/or high visibility cases and analyzed and researched risks associated with those cases, and recommended appropriate measures to manage risks.
- Investigated and analyzed premium discrepancies between company records and the customer’s information and initiates corrective action.
- Communicated with customers around outstanding accounts receivable balances to ensure accuracy and timely payment of amounts due.
- Developed a test plan and suite to validate data extraction, transformation, and loading using SQL and Microsoft Excel.
- Audited payment information received from customer with expected premium to be received from the customer. Resolved any variances with the customer and internal departments to ensure accuracy of payments received and accounts receivable balances.
- Wrote SQL queries extensively to retrieved data from the database.
- Communicated timely with the customer and internal departments to ensure discrepancies are reconciled to maximize cash flow and minimize financial impact to the company.
- Lead and participated in broker/customer meetings to find solutions to customer issues and problems, as well as negotiate with tact and diplomacy to find a solution that is win-win.
- Mentored, coached, and assisted with the development of the training of staff; reviewed the work of others to check for quality, compliance and process consistency. Provided technical expertise to internal and external customers around billing. Documented best practice procedures.
- Lead process improvement initiatives to improve productivity, accuracy, and/or customer service. Identified and works with appropriate resources to address any upstream/downstream impact from process changes/modifications.
Provider Configuration Lead
Evolent Health LLC
Chicago, USA
03.2018 - 05.2019
- Supported Business Process Improvement with configuration and maintenance.
- Configured Benefit Plans, Sponsors and Policy Plans, in QNXT, for new and existing products.
- Maintained files as well as appropriate system configuration management documentation for other future mission critical systems such as Provider Data information systems.
- Created SQL queries involving derived tables, subqueries, and correlated queries to fetch data from different tables in the SQL Server platform.
- Worked with Business Process Improvement and business unit service area management and staff to support configuration management best practices, systems enhancement processes, and management of system configuration life cycle management project/program plans, tracks configuration change operational issues and resolution.
- Utilized SQL Server to extract necessary data for Medicaid and Medicare Encounters.
- Conducted regular analysis of commercial claims performance metrics, identifying areas for improvement, and implementing data-driven enhancements to optimize operations.
- Manage and configure contract methodologies into QNXT.
- Lead activities and deliverables of provider data implementation of any system configuration enhancement or upgrade, driving continued integration with related technology solutions.
- Supported major system configuration changes and served as a subject matter expert or team liaison in configuration change management testing and related best practices.
- Communicated with various internal and external staff relating to contracting efforts for the purpose of monitoring and managing deliverables specific to the contracting team, including specific contract tasks such as: MOUs, LOAs and other ancillary contracts.
- Managed day-to-day performance monitoring of core system data and configuration and adjudication.
- Reviewed and performed root cause analysis and evaluation to determine core system issues and resolution.
Provider Data Services Team Leader
Aetna
Newark, USA
10.2017 - 03.2018
- Provided training, coaching, development and mentoring to team members to help them meet and achieve performance goals.
- Created an environment for team members that promoted positive communication, encouraged team members to interact with one another, as well as demonstrate flexibility.
- Utilized detailed SQL and Access queries to verify changes made to system configuration and conducted comprehensive claims/application testing to ensure proper benefit, contract, provider, and claim functionality.
- Conducted regular audits and quality checks on commercial claims configurations to identify and rectify discrepancies, resulting in improved claims processing efficiency.
- Motivated the team to achieve organizational goals and contribute to the overall success of the company.
- Developed and implemented timelines to achieve targets within the team.
- Delegated tasks to team members that empowered them to improve their confidence and communication skills.
- Utilized SQL for running queries to validate benefits configuration and wrote SQL scripts for efficient data manipulation and issue resolution.
- Conducted thorough audits of commercial benefit plans, identifying and resolving discrepancies to optimize system accuracy.
- Provided updates to upper management regarding individual, as well as group performance.
- Identified and analyzed trends as a result of researching and responding to claims configuration requests, problem reports, and inquiries.
- Identified areas of improvement in existing work processes and provided guidance.
- Established claims configuration management policies, procedures and tools.
- Assisted with development of claims configuration standards and best practices.
- Assessed overall claims configuration change in scope and undertake work planning for new projects.
Provider Data Services Consultant
Aetna
Newark, USA
08.2016 - 10.2017
- Processed roster updates, changes, and terms.
- Reviewed provider and pay to issues and provider load.
- Maintained the Provider Data (demographic and contractual) for all network and non-network providers.
- Ensured all provider information is accurately recorded and maintained to provide for proper reimbursement and member access (i.e., directory listings) in QNXT.
- Established, maintained, and aligned complex contracted provider demographic data and negotiated reimbursement arrangements across provider systems.
- Developed and maintained standards for database integrity, corrective action, database alignment, and managing communication processes with other departments regarding database improvements.
- Provided support for provider data transactions associated with projects, expansions, and new product implementations.
- Contributed to the design and testing of new commercial benefits configuration strategies, enhancing the company's competitive edge in the healthcare sector.
- Provided support for baseline provider data transactions that cannot be administered automatically through the provider database due to system limitations and/or data integrity issues.
- Provided ongoing support and research analysis essential to resolving concerns / issues raised by providers and other internal / external customers or representatives.
- Work and troubleshoot claims that suspend in QNXT work queues for lack of provider match in the claims processing system. This included working with IT and necessary members of management to increase auto adjudication of claims by seeking alternatives to current workflows.
- Identified, researched, and conducted root cause analysis (e.g., problem providers identified by PST, rework, and audit trends) and recommending process improvements.
- Configured and maintained benefits within the QNXT system for commercial and Medicare lines of business, ensuring accurate and compliant plan setups.
- Resolved high volume/high impact systematic problems through proactive and reactive mechanisms. (e.g., automation, route audit programs, data reporting, and root cause analysis)
- Created and managed action plans for assigned projects relative to data quality and/or workflow improvements; while ensuring that all impacted constituents are considered and appropriately addressed in action plans.
- Continuously monitored and improved commercial claims configurations to optimize accuracy, reduce errors, and enhance the overall claims processing efficiency.
- Provided technical and/or functional leadership within the unit (i.e., team lead).
- Performed validation of system enhancements.
- Extracted information from provider systems to meet business reporting needs.
- Researched as well as identified Fraud, Waste & Abuse.
- Analyzed and loaded Medicaid contracts for providers and groups
- Other ad-hoc duties as assigned to aid team members and management.
Accident & Health Claims Representative
Ace, INA Insurance
Wilmington, USA
09.2013 - 07.2016
- Reviewed and processed medical, dental, repatriation, emergency evacuation, personal effect, disability, as well as Accident and Health TPA claims via Mitchell Billing and FoxPro Systems.
- Made timely and appropriate contacts, determined and completed appropriate level of investigation to make determination of coverage as well as damages.
- Independently determined exposure, established initial reserves, and made timely adjustments as required.
- Conducted research on claims to identify possible Fraud, Waste, and Abuse.
- Conducted claims performance, quality, and audit reviews of Accident and Health TPA’s.
- Communicated audit findings while recommending solutions for continuous process improvement.
- Managed claims while working under tight deadlines with limited oversight.
- Re-Priced claims and validation of coverage through international ACE Offices.
- Worked with international providers and assistance companies on benefit validations.
- Prepared and processed wire transfers for international payments.
- Provided customer service to claimants, providers and business units on claim processing.
- Worked closely with team members as well as management to communicate claim issues, recommend changes, and assist in improving claim processes while ensuring that departmental goals are achieved.
- Provided monthly activity reports.
- Documented clearly and concisely all relevant activity on assigned files and made recommendations for additional activity as appropriate.
- Anticipated and met all internal and external customer / claimant needs.
Medical Claims Processor
State Farm Insurance
Concordville, USA
02.2012 - 09.2013
- Applied MPC claims settlement procedures to review and process claims, initiate claim payments, and close claim files through Enterprise Claims Systems and Mitchell Billing System.
- Applied appropriate contractual provisions from the policyholder plan regarding eligibility and exclusions.
- Determined on a timely basis, the eligibility and or liability of assigned claims.
- Determined whether additional evidence was required including but not limited to accident reports, accident scene reconstruction, witness statements, police reports etc.
- Communicated clearly, professionally, and empathetically with claimants and associates over the telephone, in person, email, and written correspondence, as well as taking recorded statement.
- Independently determined and negotiated proper settlement within authority.
- Researched claims to identify possible fraud.
- Worked in a collaborative team environment to handle a large volume of claims and telephone calls.
- Maintained quality work, organizing, prioritizing, and meeting deadlines for MPC claims.
- Determined and demonstrated when and how resources (both internal and external), e.g., medical, investigative, and legal added value to processes.
- Prepared written rationale of claim resolution based on review of the contract, plan documentation and the evaluation of medical records.
- Applied knowledge of the U.S health care industry, including regulatory/statutory guidelines, HIPAA, privacy, and the Affordable Health Care Act, as well as a working knowledge of medical terminology and coding (ICD-10, HCPCS, etc.)
- Maintained a block of business and continuously met departmental metrics.
- Established cooperative and productive relationships with internal and external business partners.
Education
Bachelor of Science - Criminal Justice
Drexel University
Philadelphia, PAWidener University
Chester, PASkills
- Claims Review
- Claims Processing
- Auditing
- Quality Assurance
- Attention to detail
- Adaptability
- Analytical
- Process improvement
- Team collaboration
- HIPAA compliance
- Insurance regulations
- Customer service
- Administrative functions
- Health insurance
- Analytical thinking
- Team building
- Analytical skills
- Verbal and written communication
- Customer billing
- Billing inquiries
- Reliability
- Vision and dental insurance
- Time management
- Insurance practices
- Insurance eligibility
- Research skills
- Problem resolution
- Staff management
- Decision-making
- Conflict resolution
- Coaching and mentoring
- Documentation and reporting
- Contract management
- Process monitoring and improvement
- Multitasking capacity
- Organizational skills
- Multitasking
- MS office
- Computer skills
- Problem-solving aptitude
Affiliations
Business Professionals of America
Training
- MS Office (Excel, Power Point, Word, Outlook, and Access)
- QNXT
- TRIZETTO
- Facets
- Jira
- HEDIS
- Confluence
- SharePoint
- Pro Data
- Salesforce
- EIS
- FoxPro
- TCSYS
- Mitchell Billing
- Pega
- Stars
- Enterprise Claim System
- Medicaid
- Medicare
- Medical Claims
- Medical Coding (ICD-10, HCPCS)
- Box
- CMS Government IDRE
Awards
- Cap Award Recipient, 2010
- Customer Commendation Award Recipient
- 2013
- 2014
- VOC Award Recipient
- 2022
- 2023
Timeline
Health Insurance Specialist
Provider Resources
02.2023 - Current
Sr. Billing Analyst Dental & Vision
AFLAC
03.2022 - 02.2023
Sr. Billing Specialist
The Hartford Insurance
07.2019 - 03.2022
Provider Configuration Lead
Evolent Health LLC
03.2018 - 05.2019
Provider Data Services Team Leader
Aetna
10.2017 - 03.2018
Provider Data Services Consultant
Aetna
08.2016 - 10.2017
Accident & Health Claims Representative
Ace, INA Insurance
09.2013 - 07.2016
Medical Claims Processor
State Farm Insurance
02.2012 - 09.2013
Bachelor of Science - Criminal Justice
Drexel University
Widener University