LaSheik Calhoun
Winston-Salem,NC
Summary
Highly trained Claims Specialist with a proven track record of claim processing efficiency and provider satisfaction through expert knowledge of Medicare/Medicaid regulations and claim processing expertise. Skilled in navigating Facets and consistently achieving accurate and timely claim resolutions.
Overview
6
6
years of professional experience
Work History
Senior Claims Specialist
Blue Cross NC
10.2022 - Current
- 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 Customer Service Representative
Blue Cross 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
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
Winston-Salem, NCCertificate - Pharmacy Technology
Forsyth Technical Community College
Winston-Salem, NCSkills
- Claims Processing
- Microsoft Office
- Critical Thinking
- Documentation Review
- Facets Experience
- Medicare Advantage Understanding
- Teamwork and Collaboration
- HIPAA Compliance
- Claims adjustment
- Data Entry
- ICD-10 Proficiency
- Accuracy and Precision
Timeline
Senior Claims Specialist
Blue Cross NC
10.2022 - Current
Provider Customer 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
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