Keianna Johnson
Jacksonville
Summary
Analytical Quality Control Analyst with expertise in implementing and enhancing quality assurance processes. Achieved improved product reliability and consistency through effective data analysis, regulatory compliance, and process improvement initiatives. Led cross-functional teams to identify discrepancies and develop corrective actions that reduced errors and increased customer satisfaction.
Overview
4
4
years of post-secondary education
15
15
years of professional experience
Work History
Analyst, Quality Audit Control l OPS
CVS health
Jacksonville
12.2024 - Current
- Conduct regular, routine audits to ensure compliance with plan documents.
- Executed audits, analyzed quality metrics to ensure accuracy and compliance.
- Perform analysis on defects and recurring issues to identify the root cause of quality issues.
- Gathered documentation, provided evidence of compliance for internal/external audits, supporting maintenance of high standards.
- Document all Audit findings and provide feedback to operational staff as well as report results to senior management.
Claims Benefit Specialist
CVS health
Jacksonville
03.2020 - 12.2024
- Review and adjudicate routine Medicare claims in accordance with claim processing guidelines.
- Analyzed and approved routine and high dollar claims requiring manual adjudication, ensuring compliance with processing standards.
- Reviewed and applied appropriate guidelines for claim and referral submissions, including coding for procedures and diagnoses.
- Utilized system functions to ensure accurate claim processing.
- Complied with policies of all applicable federal and state government agencies, including the Center for Medicaid and Medicare (CMS).
Lead Appeals Resolving Analyst
UnitedHealthcare
Jacksonville
05.2017 - 10.2019
- Responsible for providing expertise or general support to teams and assisting with new hires in reviewing, researching, investigating, negotiating, and resolving all types of appeals and grievances.
- Identified trends and emerging issues, proposing actionable solutions to enhance appeal resolution processes.
- Communicate with members, providers, and other departments to ensure that all information received is accurate and up to date.
- Researched standard plan design, certification of coverage, and contractual deviations to ensure accuracy and appropriateness of benefit/administrative denials.
- Reading and researching Benefit language in SPDs or COCs to help determine the outcome of an appeal and grievance denial.
- Created and sent resolution letters to members and providers, ensuring clear communication of appeal outcomes.
- Drafted and delivered resolution letters to members and providers to communicate appeal outcomes clearly.
Lead Inbound, Pharmacy Customer Service Advocate
Optum Rx
Jacksonville
10.2015 - 05.2017
- Provided phone support for inbound Pharmacy Benefit Management (PBM) calls, assisted customers in placing orders, addressed general account questions, and provided updates to orders and prior-authorization status by proactively contacting external resources to resolve caller issues surrounding prescriptions.
- Provided assistance to customers in navigating Med D appeals and grievances processes.
- Facilitates, coaches, and provides leadership, for all new PBM hires. Supports and assists in individual development and implementation of team measurements for organizational goals.
- Team Quality champion; provide performance trends and analysis to fellow team members and leadership team of current and prior month results.
- Define and provide direction within areas of improvement to fellow advocates.
- Assisted in training fellow advocates on handling difficult situations, which involved conducting research and resolving problems to maintain client relationships.
- Identified and coordinated internal resources across multiple departments to effectively address client situations.
- Identify and coordinate internal resources across multiple departments to address client situations.
- Cross-trained in multiple support roles to enhance team flexibility. in Web call support for our commercial and UHC clients. Address customers with login issues, account setup and registration, identify errors, and site navigation.
Ambulatory Care Associate
Jamaica Hospital Medical Center
Jamaica
06.2011 - 08.2015
- Highly skilled in facilitating patient pre-registration, registration, and admission procedures.
- Executed clerical duties including copying, faxing, filing, and emailing to support office operations.
- Contact insurance carriers to verify patient’s insurance eligibility, benefits, and requirements.
- Request, track and obtain pre-authorization from insurance carriers within time allowed for medical services.
- Utilized available resources to accurately complete financial information in prescribed systems, ensuring compliance.
- Verified patient insurance eligibility, benefits, and requirements by contacting insurance carriers to facilitate service access.
- Distributed payment notices to insurance companies and patients to ensure timely processing. to insurance companies and patients also receive and process payments made by patients or insurance companies.
- Perform clerical duties such as copying, faxing, filing, and emailing etc.
Education
Bachelor of Arts Degree - English/Communication
St. Thomas Aquinas College
Sparkill, NY 08.2005 - 05.2009
Skills
- Quality auditing
- Compliance auditing
- Quality assurance
- Appeals management
- Appeals resolution
- Claims adjudication
- Pharmacy Benefit Management
- Reimbursement policies
- Medical terminology
- Medicare guidelines
- Medicare regulations
- Medicaid
- HIPAA compliance
- Policy interpretation
- Data analysis
- Research and analysis
- Analytical problem solving
- Microsoft Office
- Microsoft Excel
- Microsoft Word
- ECHS
- QNXT
- Quickbase
- RxHD
- Customer relationship management
- Quality control metrics
- Project coordination
- Attention to detail
- Time management
- Multitasking
- Team collaboration
- Written communication
- Verbal communication
- Strong analytical skills
- Multitasking
- Quality control metrics
- Project coordination
Timeline
Analyst, Quality Audit Control l OPS
CVS health
12.2024 - Current
Claims Benefit Specialist
CVS health
03.2020 - 12.2024
Lead Appeals Resolving Analyst
UnitedHealthcare
05.2017 - 10.2019
Lead Inbound, Pharmacy Customer Service Advocate
Optum Rx
10.2015 - 05.2017
Ambulatory Care Associate
Jamaica Hospital Medical Center
06.2011 - 08.2015
Bachelor of Arts Degree - English/Communication
St. Thomas Aquinas College
08.2005 - 05.2009