Lauana Autery
Tampa,FL
Summary
Dedicated healthcare professional with extensive experience in regulatory compliance, ensuring adherence to CMS and accreditation standards. Expertise in data analysis and communication enhances case management and documentation processes, driving efficiency and accuracy. Recognized for exceptional analytical abilities and strong communication skills, contributing to seamless operations and consistent positive outcomes. Committed to fostering a culture of compliance and excellence within healthcare environments.
Overview
18
18
years of professional experience
Work History
Specialist, Appeals and Grievances
EmblemHealth
08.2024 - 03.2026
- Coordinated all stages of appeals and grievances processes, ensuring thorough case handling and resolution.
- Conducted thorough research on claims, medical policies, and contractual benefits to facilitate effective resolution processes.
- Created and sent formal resolution letters that detailed decision-making processes and outlined future steps.
- Ensured adherence to regulatory standards while facilitating timely case resolutions.
- Managed approximately 50 incoming appeals and grievances per week.
Senior Analyst, Appeals and Grievances
Aetna
03.2018 - 07.2024
- Managed grievance and appeal processes by conducting thorough investigations and facilitating resolutions to enhance member and provider satisfaction.
- Created clear and compliant resolution letters to facilitate effective dispute resolution processes.
- Managed approximately 30 incoming appeals and grievances per day.
- Managed adherence to state and federal regulations for all appeals and grievances to ensure legal compliance.
- Led cross-functional teams in process improvement initiatives, increasing efficiency and service delivery standards.
Senior Claim Benefit Specialist
Aetna
02.2013 - 02.2018
- Reviewed and resolved complex medical claims, ensuring compliance with company policies and procedures.
- Ensured all compliance requirements were satisfied.
- Processed approximately 80 incoming medical claims per day.
- Analyzed complex benefit claims to ensure compliance with policy guidelines.
- Collaborated with cross-functional teams to streamline claims processing procedures.
Claim Benefit Specialist
Aetna
01.2008 - 01.2013
- Analyzed and resolved claims, maintaining adherence to regulatory standards and facilitating timely outcomes.
- Conducted thorough evaluations of specialized claims, applying plan guidelines to verify medical necessity and eligibility for coverage.
- Analyzed payment records against established fee schedules and contracts to ensure compliance and accuracy in reimbursements.
- Processed approximately 100 incoming medical claims per day.
- Evaluated claims for accuracy and compliance with company policies.
Education
Diploma - General Studies
Alliance High School
Alliance, OhioSkills
- Proficient in Microsoft Office Suite
- Knowledge of CMS regulations
- Medical Terminology
- Proficient in HCPCS/CPT coding
- Proficient in UB-04 and CMS-1500 processing
- Knowledge of HIPAA regulations
- Strong written and verbal communication
- Proficient in electronic medical records (EMR)
- Customer relations
- Expert problem solving
- Analytical thinking
- Documentation management
Timeline
Specialist, Appeals and Grievances
EmblemHealth
08.2024 - 03.2026
Senior Analyst, Appeals and Grievances
Aetna
03.2018 - 07.2024
Senior Claim Benefit Specialist
Aetna
02.2013 - 02.2018
Claim Benefit Specialist
Aetna
01.2008 - 01.2013
Diploma - General Studies
Alliance High School