LaSheik Calhoun
Winston-Salem,NC
Summary
Results-oriented Claims Specialist bringing hands-on claims processing and adjusting experience with exceptional leadership and communication skills. Background includes over 15 years of dental, hospital, medical and pharmacy claims processing with experience in Federal, Medicare and Medicaid insurance programs.
Overview
6
6
years of professional experience
Work History
Claims Specialist 2
Blue Cross NC
Durham, NC
10.2022 - 06.2024
- Initiated and responded to faxed and written correspondence from medical providers to ensure timely reimbursement
- Collaborated with interdisciplinary teams to ensure smooth processing and accurate reimbursement of Medicare Advantage claims.
- Researched, adjudicated and resolved Medicare Advantage 40 claims per hour within Amisys, Facets and Macess claims processing applications to support timely processing.
- Handled complex Medicare Advantage claims with multiple parties involved, effectively managing priorities and deadlines to ensure timely resolutions.
Provider Service Representative
Blue Cross NC
Durham, NC
01.2020 - 08.2021
- Developed rapport with providers through active listening and empathetic communication, resulting in enhanced satisfaction levels.
- Navigated multiple FEP knowledge banks and claim systems to retrieve accurate information to assist providers effectively.
- Educated providers on FEP claims procedures, authorization guidelines, and reimbursement policies for optimal claim submissions.
- Managed approximately 80 incoming calls, emails, faxes per day with efficiency from providers
Claims Specialist
Aetna
High Point, NC
07.2018 - 01.2020
- Reduced errors in claims submissions through meticulous attention to detail and thorough review processes.
- Skillfully navigated Medicare/Medicaid regulations in order to secure maximum reimbursement rates for qualifying services provided.
- Served as subject matter expert on hospital claims processing, providing guidance to colleagues seeking assistance with challenging cases or unique scenarios.
- Improved claim processing efficiency by accurately reviewing and validating approximately 200 hospital claims per day for reimbursement.
Education
Certificate - Medical Terminology
Forsyth Technical Community College
Certificate - Pharmacy Technology
Forsyth Technical Community College
Skills
- Microsoft Office
- Written and verbal communication
- Documentation review
- Teamwork and Collaboration
- Provider outreach
- Excellent organization skills
- Claims processing
- Multitasking
- Customer service and support
- Time Management
Timeline
Claims Specialist 2
Blue Cross NC
10.2022 - 06.2024
Provider Service Representative
Blue Cross NC
01.2020 - 08.2021
Claims Specialist
Aetna
07.2018 - 01.2020
Certificate - Medical Terminology
Forsyth Technical Community College
Certificate - Pharmacy Technology
Forsyth Technical Community College