LaToya Rowan
Zachary,LA
Summary
Highly organized and motivated person eager to apply time management and organizational skills in various environments. Seeking opportunities to expand skills while facilitating company growth. Timely worker with success at detailed reviews and accuracy. Committed to excellent services. Well-versed in coordinating multiple, concurrent projects. Dedicated to delivering results quickly and in line with expectations.
Overview
14
14
years of professional experience
Work History
Business Analyst I
Kforce Professional Staffing
Tampa , FL
06.2023 - Current
- Managed projects and served as primary liaison between client and multiple internal groups to clarify goals and meet standards and deadlines.
- Review large volumes of claims to determine if they were processed appropriately.
- Analyze trends in claims processing issues and identify work process solutions using Amisys
- Amisys auto load Benefits configuration from Excel spreadsheet
- Review Account Receivables received from providers, document root cause and provide feedback based on state guidelines and provider contract
- Complete analysis on the files provided based on the TAT
- Review Trended issues to determine root cause and identify system inefficiencies for processing claims
- Monitored changes in system configurations to ensure compliance with organizational policies and procedures.
- Implemented new configurations based on customer requirements
Sr. Data Processor
Cognizant Technology Solutions
College Station, TX
01.2017 - 06.2023
- Analyze and identify trends and provide reports as necessary
- Input data into system using Amisys
- Coding and processing of claims along with coordinating benefits using Amisys system
- Utilize HCPC and ICD-10 reference manuals
- Maintains knowledge of HIPAA guidelines
- Provide expertise or general claims support by reviewing, researching, investigating, negotiating, processing and adjusting claims
- Consistently meet established productivity, schedule adherence and quality standards
- Educate providers regarding policies and procedures related to referrals, claims submission, credentialing documentation, web site education, Electronic Health Records, Health Information Exchange, and Electronic Data Interface
- Determines whether to return, pay or deny claims following organizational policy and procedures which may include initial claims entry or claims which have suspended
- Researches claims as needed, assuring that quality levels are achieved
- Perform other contracting duties as requested, including but not limited to recommending changes to pricing subsystems, submitting changes to provider related database information and assisting in the completion of special projects
- Responsible for understanding all aspects of Medicaid/Medicare billing in order to file claims with all appropriate revenue, CPT4, and HCPCS codes
- Process appeal and grievance claims when received on special projects
- Collaborate with various business units to resolve claims issues or provider to ensure prompt and accurate claims adjudication
- Research and process resubmission claims that were rejected or denied
- Identified errors in data entry and related issues by mentioning to supervisors for resolution.
- Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
Clinical Administrative Coordinator
United Health Group
Baton Rouge, LA
05.2017 - 08.2018
- Responds to Incoming Provider and Enrollee calls
- Resolve Customer Service Inquiries
- Entering notifications and Provider’s status of an existing notification
- Verify status of insurance eligibility
- Assist with faxes and emails
- Appropriate referrals to Case Management staff
- Document case information completely and accurately in a timely manner
- Constantly met established productivity, schedule adherence, and quality standards while maintaining good attendance
- Responsible for understanding all aspects of Medicaid/Medicare billing in order to file claims with all appropriate revenue, CPT4, and HCPCS codes
Claims Liaison II
Louisiana Healthcare Connections dba Centene Corp
Baton Rouge, LA
07.2016 - 04.2017
- Analyze trends in claims processing issues and identify work process solutions using Amisys
- Lead meetings with various departments to assign claim projects priorities and monitor days in step processes to ensure the projects stay on track
- Audit check run and send claims to the claims department for corrections
- Document, track and resolve all plan providers’ claims projects and provider complaints to better streamline the workflow and process
- Identify authorization issues and trends and research for potential configuration related work process changes
- Interacts with network providers and health plans regularly to manage customer expectations and provider complaints and ensure issues are fully resolved
- Review all Medicaid Bulletins for changes and updates and submit change requests (CRs) to update payment system
- Responsible for understanding all aspects of Medicaid/Medicare billing in order to file claims with all appropriate revenue, CPT4, and HCPCS codes
- Identify and system changes and work and notify the plan CIA manager to ensure its implementation
- Run claims reports using pivot tables, vlookups regularly through provider information systems
- Run reports to obtain data according to the Louisiana State Legislation Act 710, regarding provider claims submitted to MCE’s to get claim acceptance/ rejection rate by the MCE’s
- Along with claim paid and denial rate and average TAT for the MCE’s to process the claims
- Assist with the development and maintenance of the provider network to ensure the Network Adequacy Reports are within CMS guidelines
- Responsible for reviewing policy documents in relation to Medicare, Medicaid or other health insurance programs
- Assist in the writing work processes and continual auditing of the processes to ensure configuration, state mandates, benefits, etc
- Developed, implemented and maintains SOP and contract compliance according to CMS regulations and guidelines
Claims Liaison I
Louisiana Healthcare Connections dba Centene Corp
Baton Rouge, LA
04.2015 - 07.2016
- Audit check run and send claims to the claims department for corrections
- Identify any system changes and work to notify the Plan CIA Manager to ensure its implementation
- Collaborate with the claims department to price pended claims correctly
- Document, track and resolve all plan providers claims projects
- Run claims reports using pivot tables and vlookups regularly through provider information systems
- Collaborate with various business units to resolve claims issues to ensure prompt and accurate claims adjudication
- Input data into the system using Amisys, CRM, Compliance 360 Database, Centelligence (MicroStrategy) and Portico
- Responsible for understanding all aspects of Medicaid/Medicare billing in order to file claims with all appropriate revenue, CPT4, and HCPCS codes
- Identify and system changes and work and notify the plan CIA manager to ensure its implementation
- Research the claims on various reports to determine if appropriate to move forward with recovery due to non-covered items being allowed, etc
- Run claims audit reports for duplicates, payments/denial review, and/or adjustments as necessary
- Assist with check-runs
- Research the claims on various reports to determine if appropriate to move forward with recovery due to non-covered items being allowed, etc.
Clinical Administrative Coordinator
United Health Group
Baton Rouge, LA
02.2015 - 04.2015
- Responds to Incoming Provider and Enrollee calls
- Resolve Customer Service Inquiries
- Verify status of insurance eligibility
- Entering notifications and Provider’s status of an existing notification
- Assist with faxes and emails
- Appropriate referrals to Case Management staff
- Document case information completely and accurately in a timely manner
- Constantly met established productivity, schedule adherence, and quality standards while maintaining good attendance
Supervisor, M&B Account Maintenance
Blue Cross Blue Shield of La
Baton Rouge, LA
09.2014 - 12.2014
- Oversees the daily operations of assigned staff in the unit including subsequent application and other change requests for existing groups
- Oversees compliance mandates coming from federal and state regulatory agencies
- Ensures performance standards and quality goals for the unit
- Mentors and coaches team members assigned to then unit
- Accountable for complying with all laws and regulations associated with the duties and responsibilities
- Directs and coordinates workload and ensures complex cases that require special expertise in the unit are resolved in a timely manner
- Supervised 15-20 non-exempt staff as direct reports
- Reviews and tracks staff performance in order to identity process deficiencies, and implement training or corrective actions to ensure that errors identified are corrected in a timely manner, and production quality standards are being met
- Participates in corporate and other projects as assigned by management
- Monitors outsourcing relationships and communicates with vendor on relates issues to ensure quality standards and service level agreements are being met
- Performs administrative functions for the unit, including but not limited to, time keeping, payroll process, PTO, approving work schedules, etc
- Logs in daily inventory to tracking dashboard to monitor daily inventory and ensure management has knowledge of inventory level
- Hired team members and trained in collaborative team environment.
- Served as liaison between certain departments to implement new improvement plans and changes.
- Resolved customer complaints and adjusted policies to meet changing needs.
- Coached staff members to develop long-term career goals.
Special Claims Processor /Claims Specialist (Team Lead)
Blue Cross Blue Shield of La
Baton Rouge, LA
09.2011 - 09.2014
- Research member and provider accounts to identify system problems, enrollment and benefit information for accurate claims processing
- Input data into system using Facets, Direct, IPD, and Legacy
- Process claims using Facets and FEP Direct system
- Utilize HCPC and ICD reference manuals
- Maintains knowledge of HIPAA guidelines
- Reviews processed claims and inquiries to determine corrective action which can include claims adjustments
- Utilize FEP claims manual and Share Point
- Research and process resubmission claims that were rejected or denied
- Work special projects and reports, responsible for releasing high dollar claims
- Serve on deferral task force
- Developed, implemented and maintains SOP and contract compliance according to CMS regulations and guidelines
- Coding and processing claims for the FEP department, along with coordinating benefits
Account Advisor
Blue Cross Blue Shield of LA
Baton Rouge, LA
02.2010 - 09.2011
- Assist plan members and providers with claims status and benefits information
- Provide excellent customer service and support
- Insurance verification
- Assist with the processing of claims and the coordination of benefits
Education
Licensed Vocational Nurse-Diploma - Vocational Nursing
Summit Career College
Anaheim, CA06.2006
High School Diploma -
Villa Park High
Orange, CA06.1999
Bachelor of Science - Healthcare Administration
Southern New Hampshire University
Hooksett, NHSkills
- Type 45 wpm
- Proficient with Microsoft Word, Excel, Powerpoint
- Data processing
- Error identification
- Verifying data accuracy
- Reporting and documentation
- Email communications
References
References References are available on request.
Timeline
Business Analyst I
Kforce Professional Staffing
06.2023 - Current
Clinical Administrative Coordinator
United Health Group
05.2017 - 08.2018
Sr. Data Processor
Cognizant Technology Solutions
01.2017 - 06.2023
Claims Liaison II
Louisiana Healthcare Connections dba Centene Corp
07.2016 - 04.2017
Claims Liaison I
Louisiana Healthcare Connections dba Centene Corp
04.2015 - 07.2016
Clinical Administrative Coordinator
United Health Group
02.2015 - 04.2015
Supervisor, M&B Account Maintenance
Blue Cross Blue Shield of La
09.2014 - 12.2014
Special Claims Processor /Claims Specialist (Team Lead)
Blue Cross Blue Shield of La
09.2011 - 09.2014
Account Advisor
Blue Cross Blue Shield of LA
02.2010 - 09.2011
Licensed Vocational Nurse-Diploma - Vocational Nursing
Summit Career College
High School Diploma -
Villa Park High
Bachelor of Science - Healthcare Administration
Southern New Hampshire University
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