KRISTY CALDWELL
Summary
Dynamic Senior Appeals Processing Associate with a proven track record at Cigna Healthcare, excelling in compliance and workflow management. Adept at auditing and reporting, I have effectively trained teams while achieving high accuracy in Medicare appeals processing. My expertise in Microsoft Office and commitment to continuous improvement drive successful outcomes in fast-paced environments.
Overview
19
19
years of professional experience
Work History
SENIOR APPEALS PROCESSING ASSOCIATE
CIGNA HEALTHCARE
05.2017 - Current
- Research appeals and claims that have not been approved for payment.
- Support personnel with all aspects of Medicare and Medicaid claims.
- Ensured compliance with deadlines by proficiently analyzing and handling Medicare/Medicaid appeals.
- Managed the end-to-end process of researching, validating, launching Cigna Medicare/Medicaid appeals requested by stakeholders.
- Executed calls to collect additional data required for processing Medicare appeals.
- Exhibited effective communication while managing tasks autonomously.
- Analyze and evaluate documents.
- Assessed documentation for Medicare appeals to establish requester.
- Ensured precise determination of medical appeal categories including Pre-Service Expedited, Pre-Service Standard, and Post Service.
- Reviewed all documentation and cases sent to Part C Appeals, determining the nature of each document.
- Analyzed relevant documents pertaining to medical appeals.
- Compose official correspondence addressing various issues.
- Tasked with managing the loading of appeal requests.
- Expertise in utilizing various software for electronic notations.
- Leverage internal resource tools when loading Medicare appeal requests.
- Monitored changes and updates in CMS Medicare policies.
- Guide newly hired staff through the steps and procedures of Medicare appeals.
ASSOCIATE CLAIMS REPRESENTATIVE
UNITED HEALTHCARE
03.2016 - 05.2017
- Researched and analyzed Medicare/Medicaid claims through various computer systems.
- Captured essential data required for accurate processing.
- Processed claims by following CMS/Medicare guidelines and benefit plan documents accurately.
- Executed daily data entry to document and communicate claim statuses.
- Resolved claim errors through effective communication with team members and providers.
- Evaluated new systems and training materials to guarantee proper application of claim procedures.
- Achieved targets in accuracy, quality, member satisfaction and attendance.
CUSTOMER SERVICE SPECIALIST
VERIZON WIRELESS
10.2015 - 03.2016
- Addressed customer inquiries regarding calling plans, features, account balances, and billing charges.
- Explained application procedures for new wireless phone lines.
- Addressed a wide range of technical concerns related to wireless devices.
- Managed and executed phone upgrades for multiple clients.
- Secured payment arrangements on delinquent customer accounts.
ADMIN ASST 2
STATE OF TENN - DEPT OF LABOR & WFD
09.2014 - 09.2015
- Delivered comprehensive Excel spreadsheets to various colleges outlining payment details.
- Ensured biweekly updates of financial data in Excel.
- Handled weekly reimbursement requests for transportation expenses.
- Facilitated reimbursement transactions for private and public academic institutions.
- Contributed to the testing phase of the VOS (Virtual One-stop) case management system.
- Matched and appended correct files to each incoming message that needed a reply.
- Supplied comprehensive tuition fees data to educational institutions.
- Performed thorough payment searches to retrieve requested information for customers.
Consumer Relations Rep
AO Smith Corporation
07.2006 - 09.2014
- Conducted prompt communication with clients regarding payment status of delinquent accounts.
- Processed and resolved unpaid warranty tank claims by working directly with customers.
- Analyzed the Ferguson vendor spreadsheet to manage parts and tank claim debits on a weekly basis.
- Facilitated efficient and correct management of warranty claims.
- Designed detailed reports to facilitate tracking and auditing.
- Handled processing tasks for 90% of warranty tank claims each month.
- Handled various warranty tank claims for numerous clients.
- Managed the end-to-end process of researching and handling debits at Lowe's.
- Provided support to customers on account-related questions.
- Conducted research to address unpaid invoices and deductions in the Southeast region for Reliance/Retail.
- Retrieved past due payments by proactively contacting various clients.
- Created accurate financial reports outlining accounts receivable information.
- Investigated and addressed invoice discrepancies.
- Contributed to the development and implementation of document acquisition systems.
Education
BACHELOR OF SCIENCE - CRIMINAL JUSTICE
TENNESSEE STATE UNIVERSITY
Skills
- Auditing
- Data entry
- Reporting and documentation
- Proficient in Microsoft Office/MHK/Facets/Citrix
- Workflow management
- Industry awareness
- Compliance
- Standard operation procedures
- Team Training
- Performance improvement
- Process flows
- Continuous improvement
References
References available upon request.
Timeline
SENIOR APPEALS PROCESSING ASSOCIATE
CIGNA HEALTHCARE
05.2017 - Current
ASSOCIATE CLAIMS REPRESENTATIVE
UNITED HEALTHCARE
03.2016 - 05.2017
CUSTOMER SERVICE SPECIALIST
VERIZON WIRELESS
10.2015 - 03.2016
ADMIN ASST 2
STATE OF TENN - DEPT OF LABOR & WFD
09.2014 - 09.2015
Consumer Relations Rep
AO Smith Corporation
07.2006 - 09.2014
BACHELOR OF SCIENCE - CRIMINAL JUSTICE
TENNESSEE STATE UNIVERSITY