Medical Investigator / Standards-of-Care Investigator
Arizona State Medical Board
09 2024 - 09 2025
Hi, I’m
Lisa Burgeson
Glendale,AZ
Summary
Medical investigator and healthcare operations professional with more than nine years of experience in standard-of-care investigations, expedited appeals and Medicare Advantage member support, complemented by a background in office administration and customer service. Skilled in medical record analysis, evidence collection, investigative reporting, regulatory compliance, and complex case resolution. Managed approximately 120 active investigations, handled expedited appeals within strict 72-hour deadlines, Additional strengths include new-hire training, provider and member communication, vendor coordination, and administrative support, with a consistent commitment to accuracy, confidentiality, and timely service.
Work History
Arizona State Medical BoardPhoenix
Medical Investigator / Standards-of-Care Investigator
09 2024 - 09 2025
Job overview
- Managed an active caseload of approximately 120 complex medical investigations involving alleged standard-of-care violations, systematically analyzing clinical records to identify and extract key evidentiary findings.
- Authored comprehensive investigative reports and presented substantiated standard-of-care deviation cases directly before the Medical Board in support of disciplinary and licensing actions.
- Conducted targeted interviews with witnesses, patients, and healthcare providers across concurrent active cases, maintaining full adherence to regulatory and confidentiality requirements.
- Applied clinical expertise and analytical judgment to resolve high-stakes cases, consistently meeting a strict 90-day turnaround deadline without compromising investigative rigor.
- Prepared evidentiary exhibits, timelines, and case summaries for presentation at administrative hearings and disciplinary proceedings.
- Communicated case outcomes and procedural rationales clearly to complainants, licensees, and key stakeholders.
HumanaLouisville
Expedited Appeals Specialist
05 2021 - 06 2024
Job overview
- Directed the full lifecycle of high-priority expedited appeals, evaluating medical records to establish medical necessity within strict 72-hour deadlines.
- Triaged incoming appeals by urgency, clinical risk, and regulatory deadline, ensuring high-priority cases were prioritized effectively.
- Drafted robust determination letters and denial rationales using clear, defensible language aligned with regulatory standards.
- Partnered with medical directors and clinical reviewers on complex cases requiring physician-level medical necessity determinations.
- Documented all case activity within appeals tracking systems to ensure continuous audit readiness and accurate turnaround-time reporting.
- Resolved complex claim disputes through direct coordination with providers, maintaining transparent communication and detailed case files.
- Served as the primary liaison for provider inquiries, delivering consistent updates and documentation throughout the dispute lifecycle.
- Identified denial trends and recurring documentation gaps, reporting findings to utilization management and provider relations teams to mitigate future issues.
- Collaborated cross-functionally with claims, utilization management, and compliance teams to resolve complex eligibility and documentation discrepancies.
- Adjudicated appeals under accelerated schedules while safeguarding patient rights and ensuring strict compliance with CMS and state regulations.
- Applied CMS and state coverage criteria to each determination, documenting the formal regulatory rationale for all approvals and denials.
- Protected member appeal rights by issuing timely, compliant notifications detailing decisions, clinical rationale, and subsequent appeal options.
- Ensured ongoing compliance with industry standards, regulatory mandates, and payer-specific guidelines at every stage of the appeals process.
- Compiled and structured comprehensive case files and supporting exhibits for external reviews, state inquiries, and federal audits.
- Maintained an up-to-date knowledge of payer-specific guidelines and regulatory updates, promptly aligning case-handling protocols with evolving standards.
Blue Cross Blue Shield of Arizona – Federal Employee ProgramPhoenix
Claims Processor / Claims Analyst
08 2019 - 05 2021
Job overview
- Processed and adjudicated complex medical claims with high accuracy, resolving discrepancies through comprehensive reviews of clinical documentation.
- Verified member eligibility, benefit structures, and provider network status prior to claims adjudication.
- Investigated coding and billing discrepancies, liaising with healthcare providers to secure missing or corrected clinical documentation.
- Maintained detailed, auditable records of claim decisions to support quality assurance evaluations and regulatory compliance.
- Delivered high-quality customer service by promptly resolving inquiries and educating members on policy benefits and claim statuses.
- Acted as a subject matter expert for member and provider inquiries regarding benefits, adverse determinations, and appeal rights.
- Articulated complex coverage determinations in accessible language to help members navigate policy terms and financial responsibilities.
- Documented all member and provider interactions within the CRM system to ensure accurate audit histories and continuity of care.
- Decreased claims turnaround times by 50% through workflow optimization and targeted process improvements.
- Analyzed operational bottlenecks and re-engineered intake and review workflows, eliminating redundant touchpoints.
- Standardized clinical documentation requirements, substantially reducing back-and-forth communication and resubmissions.
- Collaborated with team leadership to deploy streamlined workflows and track key turnaround metrics.
Blue Cross Blue Shield of Arizona – Medicare AdvantagePhoenix
Customer Service Representative
05 2016 - 08 2019
Job overview
- Served as an escalation point of contact for complex cases requiring critical judgment beyond standard operating procedures.
- De-escalated grievances from dissatisfied members by pinpointing root causes and executing resolutions consistent with plan policies.
- Tailored communication strategies for older adult members, utilizing clear, patient explanations to ensure complete comprehension of complex coverage details.
- Partnered with claims, appeals, and provider relations departments to efficiently resolve cross-functional issues.
- Analyzed dispute and resolution data to identify systemic pain points and propose ongoing operational improvements.
- Educated members and providers on Medicare Advantage benefit coverage, claims adjudication, and appeals procedures while meticulously documenting interactions in CRM platforms.
- Explained benefit structures, cost-sharing, network requirements, and Medicare-specific rules such as enrollment periods and coverage determinations in clear, member-friendly language.
- Guided providers through claims submission requirements and Medicare Advantage appeal and grievance filing procedures.
- Maintained detailed, compliant CRM records to support continuity of service and audit readiness.
- Conducted systematic follow-up communications to ensure complete issue resolution and enhance member satisfaction.
- Established follow-up cadences so no case closed without confirmed member acknowledgement.
- Monitored open cases to completion, escalating unresolved items before they breached CMS service-level targets.
- Captured follow-up outcomes to measure resolution quality and inform coaching and process changes.
- Collaborated with the corporate trainer to deliver new-hire training, co-facilitating a four-week classroom program covering core job functions and service expectations.
- Instructed new hires on claims and appeals procedures, CRM documentation standards, and member communication techniques.
- Prepared and delivered training materials, practice scenarios, and knowledge checks to reinforce retention.
- Coached trainees through live-call shadowing and provided feedback on performance during the onboarding period.
- Assessed trainee readiness against program milestones, flagging individuals needing additional support to the corporate trainer.
Simpson Tool BoxPhoenix
Front Desk & Office Support / Administrative Assistant
09 2005 - 09 2010
Job overview
- Served as the primary point of contact for incoming calls, fielding general inquiries and routing callers to the appropriate departments with accuracy and professionalism.
- Managed all special-order purchasing, including vendor communication, order tracking, and proactive follow-up with customers to confirm delivery timelines.
- Coordinated local pickups and deliveries, serving as the liaison between customers, drivers, and warehouse staff to ensure on-time fulfillment.
- Maintained accurate inventory records, monitoring stock levels and flagging shortages or discrepancies to support continuous product availability.
- Partnered with the sales department to provide order status, product details, and administrative support during peak periods.
- Demonstrated strong commitment and reliability by working extended hours, including overtime and weekends, to meet business demands.
- Designed and presented a new aftermarket accessories catalog to company ownership; the catalog was approved, printed, and adopted as the company's official publication.
- Supported the online sales division with order processing, customer correspondence, and product information as needed.
- Assisted the office manager with bookkeeping tasks, including invoice processing, data entry, and record reconciliation.
Education
Northwest Christian AcademyPhoenix
High School Diploma
01.1995
Glendale Community CollegeGlendale
Associate's Degree from Business Management
05.1997
University Overview
- Business Administration
- Management & Leadership
- Healthcare Administration
- Office Administration
Kaplan CollegePhoenix
Medical Billing & Coding Certificate
01.2013
Skills
- Clinical Documentation Auditing
- Caseload Management
- Standard-of-Care Investigations
- Board Reporting & Case Presentation
- Conflict Resolution & Call De-escalation
- Medical Record Review & Analysis
- Regulatory Compliance & HIPAA
- Healthcare Claims Adjudication
- Appeals & Grievances Management
- Witness Interviewing & Evidence Collection
- EHR/EMR Systems & Claims Platforms
- Interdisciplinary Collaboration
- Investigative Report Writing
- Administrative & Operations
- Special-Order Purchasing & Vendor Coordination
- Inventory Tracking & Reconciliation
- Logistics & Delivery Coordination
- Bookkeeping Support (Invoicing, Data Entry, Reconciliation)
- Records Management & Filing
- Mail & Shipment Processing
- Training & Leadership
- New-Hire Training & Classroom Facilitation
- Curriculum & Training Material Development
- Live-Call Coaching & Performance Feedback
- Cross-functional collaboration
- Customer Service & Member Support
- Conflict De-escalation & Issue Resolution
- Health Literacy–Adapted Communication
- Omnichannel Support (Phone, Email, Written Correspondence)
- Provider & Member Education
- Complaint Triage & Prioritization
- High-Volume Call Management
Timeline
Expedited Appeals Specialist
Humana
05 2021 - 06 2024
Claims Processor / Claims Analyst
Blue Cross Blue Shield of Arizona – Federal Employee Program
08 2019 - 05 2021
Customer Service Representative
Blue Cross Blue Shield of Arizona – Medicare Advantage
05 2016 - 08 2019
Front Desk & Office Support / Administrative Assistant
Simpson Tool Box
09 2005 - 09 2010
Northwest Christian Academy
High School Diploma
01/1995
Glendale Community College
Associate's Degree from Business Management
05/1997
Kaplan College
Medical Billing & Coding Certificate
01/2013