Leslie Spegal

Claims Unit Supervisor for TN Medicaid Provider Operations, Crossover Claims Unit. Duties include, but are not limited to the following:

• Manage a department of Claims CSRs who receive incoming calls from healthcare providers using a multi-line phone system, averaging 300-500 Inbound calls per day.
• Ensure Claims Unit CSRs follow protocol and maintain standards set forth by the State of TN, TN Medicaid, other State and Federal agencies, and TNCSA.
• Maintain employee files, disciplinary reports and reviews, time sheets and PTO requests.
• Run system reports to verify call statistics to ensure each CSR is meeting company requirements.
• Review CSR call reports to ensure all performance metrics are being met, accurate information is being communicated to the provider network, and company standards are being met.
• Support TNCSA CSRs with issues that may arise during normal daily operations, including Provider Eligibility, Provider Registration, Recipient Inquiry, and Managed Care Complaints.
• Assist providers with the verification of member coordination of benefits, verification of TN Medicaid Provider Registration; and the submission, processing, proper adjudication and payment of their Medicaid Crossover Claims.
• Assist with general inquiries pertaining to Medicare/Medicaid services, programs and coordination of services with other state and federal agencies.
• Assist providers with the verification and updating of Third Party Liability (TPL) Insurance for Dual eligible members.
• Expert working knowledge of medical billing both CMS1500 Professional claims and UB04 Institutional claims.
• Expert working knowledge of Explanation of Benefits (EOBs) and Remittance Advices (RAs) for payers such as Medicare, Medicaid, and Third Party Liability's (TPLs) or Third Party Administrators (TPAs).
• Knowledge and understanding of the calculation of payment methodologies, payer allowable amounts and contractual obligations.
• Expert working knowledge of Current Procedural Terminology (CPT) Codes, Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases, 10th Revision (ICD-10), Berenson-Eggers Type of Service (BETOS) codes and pricing Modifiers.
• Expert working knowledge of the submission and payment requirements related to the processing and adjudication of CMS1500 Professional claims and UB04 Institutional claims.
• Review medical claims and associated Explanation of Benefits for billing or processing errors, and communicate the information to the appropriate person or department for proper billing or processing.
• Submit reports and inquiries to the State of TN Bureau of TennCare, Finance & Administration, Claims Processing Vendor, State of TN Provider Registration Department, and other State Departments as needed for further research and investigation of member data, provider registration data, claim, or financial records.
• Organize quarterly Claims meetings with the State of TN, Bureau of TennCare to maintain a consistent and accurate flow of communication between all affiliated departments. Update Claims Unit CSRs post meetings, as needed.
• Communicate operational process changes to all departments, internal staff, organizational leaders, and external departments.
• Write and edit internal policies, training materials, desk procedures, and job aids within the Claims Department.
• Develop and maintain the official Claims Unit Training Manual for TNCSA.
• Train all newly hired Claims CSRs as the Claims Training Specialist.
• Work closely with organizational leaders and instructional designers to develop and update claims training curricula for various audiences, including provider claims training material, provider billing manuals, provider FAQs and more.
• Effectively negotiate operational disagreements or misunderstandings with the provider network to reach an appropriate outcome.
• Use results of claims denials, reconsideration requests, and call monitoring to refine desk procedures, training content, provider FAQs, and training materials.
• Seek advice and escalate policy and procedure issues to upper management or other departments, as warranted.
• Actively stay up to date on knowledge in all aspects of assigned TN Medicaid programs.
• Work directly with management to achieve goals and performance standards.

• Managed an average of 100-300 first and second shift temporary associates daily by verifying daily attendance, time cards, entering payroll into all payroll and accounting databases, administering drug screens, and completing employee write-ups, as required.
• Followed Workers' Compensation procedures by filing submitting Workers Comp claims to corporate office, as required.
• Completed and conducted new-hire orientations.
• Screened applicants for the best, most qualified candidate for each open position.
• Assisted department leads and supervisors by running reports, maintaining attendance records, documenting all employee write-ups and workers comp claims.

• Assisted in the initial new super center set-up of the store.
• Assembled shelving for all departments and stocked departments with applicable products.
• Assisted all customers within the store find products, and assisted as Cashier.
• Zoned and stocked shoe department.
• Receptionist - routed calls to appropriate departments within the store.

• Hostess - Greeted and seated customers as they came into the restaurant.
• Ran errands for management, ran cash register, and trained new employees.
• Kept front lobby and buffet area clean.
• Waitress - Greeted and served each customer in my assigned area.
• Stocked and cleaned area at end of shift.

• Served customers at the concession stand, ran the popcorn machine, and stocked candy shelves.
• Exchanged money by hand without the use of a cash register or calculator.