LATEIYA STARR
Aliquippa,PA
Summary
Results-driven Appeals Analyst with a proven ability to interpret complex regulations and manage projects effectively at Highmark Wholecare. Recognized for exceptional analytical skills and communication strengths, ensuring regulatory compliance and enhancing member satisfaction. Proficient in Microsoft Office and skilled in strategic task coordination, consistently meeting goals through effective time management. Committed to delivering precise analyses and fostering positive outcomes through critical thinking and problem-solving capabilities.
Overview
16
16
years of professional experience
Work History
Appeals Analyst
Highmark Wholecare
Pittsburgh, PA
10.2021 - Current
- Interpreted complex rules, regulations, policies and procedures related to appeals.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Reviewed documents for accuracy and completeness prior to processing appeals.
- Analyzed and evaluated appeals to ensure compliance with applicable laws, regulations, policies and procedures.
- Assessed customer complaints to determine eligibility for appeal or grievance filing.
- Request and review all necessary documentation.
- Prepared written responses to customers regarding the status of their appeal or grievance filings.
- Compiled data on an ongoing basis concerning trends in appeals or grievances filed.
- Facilitated hearings as a representative of the organization when necessary.
Lead Provider Services Representative
Gateway Health Plan
Pittsburgh, PA
06.2017 - 10.2021
- Provided physicians, hospitals, and third-party billers with rejected claim denials for both PA Medicare and Medicaid using DHS/CMS and company policy medical guidelines.
- Responsibilities included several projects, such as the development of a claim project, the negative balance remit pilot program, member reimbursement issues, maintaining the PA Provider Portal secure messaging system, monthly quality monitoring scoring, and completing special escalation issues given by upper management.
- Assisted providers in regard to appeals, medical reviews, and payment dispute determinations.
- Handled 30 to 50 inbound calls, assisting Medicaid and Medicare members with choosing doctors who participate and understand benefits.
- Helped members file complaints, grievances, and answered general questions and concerns.
- Educated members, providers, and pharmacies on Gateway's formulary offerings, and identified members subject to physician/pharmacy restrictions (lock-ins) according to CMS policy.
- Used purposeful execution, effective listening, probing questions, and taking action to be in compliance with GHP rules and regulations.
- Developed team communications and information for meetings.
Cobra Benefits Analyst
Wills Towers Watson/Key Personnel
Pittsburgh, PA
02.2017 - 06.2017
- Handled confidential appeal investigations with sensitivity and discretion in accordance with HIPAA, Cobra Laws, Data Privacy Laws, and company data security requirements.
- Proficiently translated health, welfare, and pension terms, complex plan information, and processes into simple explanations and instructions that Cobra members can understand and act upon.
- Demonstrated knowledge, understanding, and compliance with company and client procedures, as well as client guidelines, while providing appropriate and accurate information under the Cobra Law.
- Maintained and documented accurate call and case notes, and responded professionally to member appeals received by phone, email, or other communication channels.
- Demonstrated ability to maintain a high level of customer service in a changeable work environment, and participated in team meetings.
Products and Services Billing Analyst
Dominion Energy
Pittsburgh, PA
03.2009 - 11.2016
- Required fundamental knowledge to navigate the company's customer information systems, PeopleSoft, Oracle billing system, SAP, and/or order systems, along with a basic knowledge of company compliance, PUC rules, and regulations.
- Responsibilities include answering customer questions, explaining available commodity services, correcting errors, providing information on pricing, developing leads, scheduling move-ins, move-outs, transfers of service, renewals, determining tax exemptions, and/or selling products and services.
- Conducted a monthly pre-billing review and data quality analysis to verify the complete accuracy of invoices delivered to customers and hedge fund providers.
- Analyzed payment information and applied changes to correct customer accounts.
- Researched issues related to non-payment within e-billing vendor portals, including outstanding balances, and worked with the billing team and attorney to resolve invoice issues.
Grievance Coordinator
Air Star Access/Classy Cab
Pittsburgh, PA
05.2009 - 03.2011
- Scheduled and dispatched workers, work crews, equipment, or service vehicles to appropriate locations for PA Medicaid members for medical appointments, using two-way radios or telephones.
- Prepared relevant SRM documents in conformance with the Safety Management System (SMS) order.
- Managed a quality assurance program, including on-site evaluations, internal audits, and customer surveys.
- Provided outreach for additional information for appeals and grievances.
- Processed and finalized appeals and grievances within the agreed-upon turnaround time.
- I took notes on interviews and member transportation investigations, compiled records, and organized documentation for cases.
Education
Community College of Beaver County
Monaca, PA04-2025
Career Certificate in Business Management -
Penn Foster Career School
Scranton, PA01.2011
High School -
Schenley High School
Pittsburgh, PA01.1997
Skills
- Excellent written and verbal communication skills
- Experience in Microsoft Word
- Experience in Excel
- Experience in PowerPoint
- Strategic Task Coordination
- Effective Time Management
- Medical terminology knowledge
- Analytical thinking
Timeline
Appeals Analyst
Highmark Wholecare
10.2021 - Current
Lead Provider Services Representative
Gateway Health Plan
06.2017 - 10.2021
Cobra Benefits Analyst
Wills Towers Watson/Key Personnel
02.2017 - 06.2017
Grievance Coordinator
Air Star Access/Classy Cab
05.2009 - 03.2011
Products and Services Billing Analyst
Dominion Energy
03.2009 - 11.2016
Community College of Beaver County
Career Certificate in Business Management -
Penn Foster Career School
High School -
Schenley High School
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