Leslie Spegal

• Supervise TN Medicaid Crossover Claims Unit for TennCare Provider Operations.
• Monitor team performance, enforcing compliance with corporate claims processes and procedures.
• Champion insurance claims process by providing expert knowledge and building positive, trusting relationships to support clients and handling of their claims.
• Manage up to 500 calls daily to gather information to initiate claims process.
• Investigate, evaluate, and adjust multi-line claims in accordance with State and Federal standards and laws.
• Gather sensitive information to update customer profiles and help with appeals process.
• Document and communicate timely claims information while supporting accurate outcomes.
• Operate and monitor multi-line phone systems.
• Monitor Claims Unit CSRs to ensure all protocols and standards set forth by State of TN, TN Medicaid, other State and Federal agencies, and TNCSA, are met and maintained.
• Maintain employee files, disciplinary reports and reviews, time sheets, and PTO requests.
• Review CSR call reports to ensure Claims Unit CSRs are meeting all performance metrics, providing accurate information to provider network, and meeting all company standards.
• Support TNCSA CSRs across all Departments; including Provider Inquiry Claims Unit, Provider Eligibility, Provider Registration, Recipient Inquiry, and Managed Care Complaints.
• Review and verify member coordination of benefits in applicable databases.
• Research and analyze TN Medicaid Provider Registration/Credentialing information in all applicable databases, such as MMIS/InterChange, PDMS, CAQH, and NPPES NPI Registry.
• Review and analyze claims to verify proper submission, processing, adjudication, and payment of provider's claims.
• Review and analyze Denied claims and Explanation of Benefits for billing and processing errors, and effectively communicate information to provider and Claims Processing Vendor for proper adjudication of claim.
• Assist providers with Medicare/Medicaid services, programs, and coordination of services with other State and Federal agencies.
• Assist in verification and updating of Third-Party Liability (TPL) Insurance for TN Medicaid members within State of TN database.
• Expert working knowledge of claim submission and billing process for CMS1500 Professional claims (Outpatient Office Visit, DME, HCBS, Radiology, Ambulance) and UB04 Institutional claims (Hospital, SNF/ ICF, RHC, Rehabilitation, Clinic).
• Expert working knowledge of Explanation of Benefits (EOBs) and Remittance Advices (RAs); 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; and how Codes applied in billing.
• Expert working knowledge of claim submission and payment requirements related to adjudication of CMS1500 Professional claims and UB04 Institutional claims based on Provider Type and services billed.
• Escalate concerns and inquiries to the State of TN, Bureau of TennCare, Finance & Administration, Claims Processing Vendor, Provider Registration Department, and other State Departments as needed for additional research and investigation of member information, provider information, claims issues, or financial records.
• Develop quarterly Claims meetings with Claims Unit, Claims Processing Vendor, and Bureau of TennCare to maintain consistent and accurate flow of communication between all affiliated departments.
• Communicate operational process changes to all departments, internal staff, organizational leaders, and external departments.
• Develop and maintain internal policies, training materials, desk procedures, and job aids within Claims Department.
• Develop and maintain official Claims Unit Training Manual for TNCSA.
• Train all newly hired Claims Unit CSRs, as official Claims Training Specialist.
• Develop and maintain form templates for the Claims Unit Staff’s daily use to help streamline the call process. This includes the Daily Call Log, Financial Review Form, Reprocess Request Form, State of TN/Bureau of TennCare Contact List, TN Medicaid EOB Codes & Resolutions Cheat Sheet, and Inmate Suspension/DOD/Medicare Updates.
• Collaborate with organizational leaders and instructional designers to develop and maintain claims training curricula for various audiences. i.e., CMS1500 TennCare Provider Billing Manual, UB04 TennCare Provider Billing Manual, and TennCare Provider Crossover Claims FAQs.
• Collaborate with organizational leaders such as Director of Claims and Encounter Operations Information Systems with the State of TN; Managed Care Program Manager at the State of TN; Senior Manager of Business Process Outsourcing for TennCare; Managed Care Specialist with TennCare Provider Services; Business Analyst for the State of TN; Siebel Administrator for TennCare.
• Effectively negotiate operational and processing disagreements or misunderstandings with provider network to de-escalate and reach resolution.
• Analyze results of claim denials, reconsideration requests, and call monitoring to refine desk procedures, training content, provider FAQs, and provider training materials.
• Escalate policy and procedure issues to upper management, as warranted.
• Actively stay up to date in all aspects of assigned TN Medicaid programs.
• Work directly with management to achieve goals and performance standards.

• Interviewed, hired, and mentored over 300 new personnel and oversaw all staffing operations.
• Managed applicant tracking system (ATS) database by entering, updating, and maintaining candidate contact details, resumes, and supporting documentation.
• Developed guidelines, questionnaires, and processes for assessing, interviewing, and onboarding phases.
• Developed and facilitated new-hire orientations.
• Verified payroll, vacation, and sick time hours to support accounting processes.
• Assisted with personnel records management to support recordkeeping accuracy.
• Conducted reference checks and screening of potential candidates to support onboarding process.
• Reduced risks by enforcing compliance with federal, state, and local employment laws and regulations.
• Collaborated with department managers to determine each department's short and long-term hiring needs.
• Created and delivered HR training sessions to staff.
• Planned, monitored, and appraised employee work results by working with managers to coach and discipline employees.
• Advocated for staff members, helping to identify and resolve conflicts.
• Partnered with departmental managers to ascertain hiring needs and subsequently provide candidate recommendations.
• Completed human resource operational requirements by scheduling and assigning employees.
• Collaborated with managers to identify and address employee relations issues.
• Improved office efficiency by effectively managing internal communications and correspondence.
• Conducted performance reviews and provided feedback to managers on employee performance.
• Improved organizational filing systems for confidential employee records, resulting in improved accessibility and efficiency.
• Developed and implemented onboarding and orientation programs for new employees.
• Generated Workers' Compensation Claims, according to policy and procedure, and submitted them to Corporate office.

• Assisted in new Super-center store set-up.
• Assembled shelving and stocked departments with applicable products.
• Provided exceptional service and pleasant shopping experience to retail customers.
• Efficiently performed retail merchandising, stocking, cleaning, down stocking, and pricing.
• Enhanced product presentation and promotional material displays, working alongside retail representatives.
• Communicated with store employees to maintain conditions and appearance of retail area.
• Complied with loss prevention standards and audit requirements to support retail operations.
• Informed guests of appropriate products available to increase retail sales.
• Answered Customer Service phone line, routing all inbound calls to appropriate person or department within store using multi-line phone system.
• Assisted as backup Cashier.
• Zoned and stocked shoe department.

Hostess:

• Greeted customers warmly upon arrival and provided friendly and warm presence throughout dining experience.
• Kept Hostess station and lobby areas clean and stocked to increase efficiency while seating customers.
• Remained calm and poised when dealing with difficult customers or during busy shifts.
• Used cash registers and credit card machines to cash out customers.
• Maintained balanced cash drawer with correct money values and accurate documentation.
• Monitored seating areas and checked restrooms regularly to keep them spotless.
• Assisted managers with quickly resolving service, and food-related issues.
• Took reservations and to-go orders by phone, answered customer questions, and informed of accurate wait times.
• Assigned patrons to tables suitable for needs and restaurant section rotation.
• Answered customer questions about hours, seating, and menu information.
• Greeted new customers, discussed specials, and took drink orders.
• Resolved guest and employee complaints to maintain complete customer satisfaction and workforce effectiveness.
• Supported servers, food runners, and bussers by keeping dining area ready for every guest.
• Took reservations by phone and walk-in, keeping scheduling demands, and kitchen output in time to avoid overbooking.
• Cultivated positive guest relations by managing information and orchestrating speedy seating.
• Relayed guest comments or suggestions to manager on duty for further action.
• Accommodated special seating requests for guests to enhance satisfaction.
• Trained new hostesses on customer service best practices and restaurant policies to maintain high standards of service.
• Completed daily side work and opening and closing duties without fail.
• Organized, stocked, and cleaned establishment's front lobby during shifts to maintain welcoming appearance.
• Backed up servers by checking on tables and retrieving items for guests.
• Answered phone calls to take orders, give information, and document reservations.
• Trained new hostesses on proper food handling, customer service, and safety procedures.

Waitress:

• Maintained customer satisfaction with timely table check-ins to assess food and beverage needs.
• Collaborated with kitchen staff to facilitate prompt and accurate food preparation.
• Followed health and safety regulations relevant to hospitality industry to minimize accidents, incidents, and liability to restaurant.
• Shared knowledge of menu items and flavors, enabling customers to make personal decisions based on taste and interest.
• Used slow periods to restock supplies, ice, trays, and condiments; fold napkins and prepare silverware sets.
• Bussed and reset tables to keep dining room and work areas clean.
• Maintained customer satisfaction by clarifying questions about orders and specialty items.
• Quickly reset and cleaned up tables after customers left to enable speedy turnaround and guest flow.
• Displayed enthusiasm and promoted excellent service to customers, successfully increasing referrals and walk-in business.

• Served drinks and snacks to patrons, maintaining professionalism, and supporting individual needs.
• Monitored inventory and notified management of deficiencies or shortages.
• Maintained clean, organized workspace according to operational standards.
• Consistently provided friendly service to promote better customer engagement.
• Maintained high standards of customer service in high-volume, fast-paced operations.
• Processed customer payments by handling cash and dispensing change by hand. Cash registers and debit card machines were not used by theater during this time.
• Responded to customer complaints to help resolve issues.