Martha Dawn
Victoria,TX
Summary
Senior Appeals Analyst with extensive experience in insurance claims management and analytical problem-solving. Demonstrated success in resolving high-value claims through effective communication and strategic relationship-building with payers. Expertise in ensuring compliance with HIPAA standards while driving timely payments and successful outcomes in complex cases. Results-driven Senior Appeals Analyst with a strong background in insurance claims management. Proven ability to assess claim validity, ensuring HIPAA compliance while effectively resolving disputes and driving timely payments.
Overview
20
20
years of professional experience
Work History
Senior Appeals Analyst
Parallon Business Solutions LLC
Dallas , TX
04.2022 - Current
- Identified reasons for denied claims and collaborated with insurance carriers for resolutions.
- Reviewed technical and clinical denial arguments for reconsideration on high-value claims.
- Managed daily activities of SSC Appeals function, ensuring compliance with operational and SOX criteria.
- Monitored reports to identify claims issues, collaborating with adjusters for resolution.
- Acted as intermediary between insurance companies and customers, assessing claim validity.
- Checked documentation for appropriate coding, correcting errors and making necessary revisions.
- Updated patient and insurance data accurately in company computer system.
- Calculated refunds, premiums, and adjustments with precision.
Collections Senior Analyst
Parallon Business Solutions LLC
Dallas, TX
06.2024 - 06.2025
- Reviewed technical and clinical denial arguments for reconsideration on high-value accounts through written and verbal communication.
- Crafted concise appeal arguments to resolve objections and secure claim payments.
- Leveraged contract protections to successfully overturn denials.
- Identified coding or clinical documentation errors, implementing timely corrections.
- Maintained effective documentation standards, establishing a strong historical record of account actions.
- Analyzed problem accounts, processes, and trends for appropriate escalation.
- Monitored payer company trends and reported findings to supervisor for further action.
- Communicated contract interpretation issues and language discrepancies to leadership as needed.
Clinical Appeals Team Lead
Parallon Business Solutions LLC
Dallas, TX
11.2018 - 04.2022
- Identified reasons for denied claims and collaborated with insurance carriers to promote resolutions.
- Monitored reports to pinpoint claims issues and worked with adjusters for prompt resolution.
- Acted as intermediary between insurance companies and customers, assessing claims validity through research.
- Checked documentation for coding accuracy, correcting errors and ensuring compliance.
- Updated patient and insurance data, meticulously inputting changes into company systems.
- Calculated refunds, premiums, and adjustments with precision to ensure accuracy.
- Triage incoming inventory for Appeal's Team while managing daily activities within the function.
- Trained new employees on procedures and best practices to meet organizational standards.
Top Dollar Account Specialist
Parallon Business Solutions
07.2017 - 11.2018
- Work insurance pools and contacts insurance companies to resolve claims that are not paid in a timely manner
- Review UB-92, EOB's, remits and payor correspondence in the course of performing account follow up and escalate any identified issues to the appropriate area for review and response to expedite claim resolution
- Maintain compliance with pool completion and requirements
- Maintain required productivity and QA standards
- Document the patients account records to identify actions taken
- Work with patients and guarantors' to resolve payer request and discrepancies to promptly resolve pending claims
- Forward all other discrepancies to Overpayments or Underpayment to their departments
- Contact payer and initiate request for payment
- Knowledge of contracted and non-contract payers
- HMO, PPO, EPO, POS, and third party reimbursement issues
- Escalate contract issues to the Manager
- Preform second validation of discrepancy reason code assigned by the Discrepancy Analyst when helping out the Underpays department
- Insurance Verification
- Document benefit verification and pre-certification
- Contact physician and/or insurance company to resolve issues regarding prior authorization or referral forms
- Calculate patient cost share
- Assign iplan accurately
- Submit monthly discrepancies to Provider Representative's
- Answer phones and respond to patient's questions
- Verify authorizations
- Submit first level appeals.
Collector
Parallon Business Solutions
06.2012 - 07.2017
- Work insurance pools and contacts insurance companies to resolve claims that are not paid in a timely manner
- Review UB-92, EOB's, remits and payor correspondence in the course of performing account follow up and escalate any identified issues to the appropriate area for review and response to expedite claim resolution
- Maintain compliance with pool completion and requirements
- Maintain required productivity and QA standards
- Document the patients account records to identify actions taken
- Work with patients and guarantors' to resolve payer request and discrepancies to promptly resolve pending claims
- Forward all other discrepancies to Overpayments or Underpayment to their departments
- Contact payer and initiate request for payment
- Knowledge of contracted and non-contract payers
- HMO, PPO, EPO, POS, and third party reimbursement issues
- Escalate contract issues to the Manager
- Preform second validation of discrepancy reason code assigned by the Discrepancy Analyst when helping out the Underpays department
- Insurance Verification
- Document benefit verification and pre-certification
- Contact physician and/or insurance company to resolve issues regarding prior authorization or referral forms
- Calculate patient cost share
- Assign iplan accurately
- Submit monthly discrepancies to Provider Representative's
- Answer phones and respond to patient's questions
- Verify authorizations
- Submit first level appeals.
Medical Reimbursement Specialist
Texas Health Resources Dallas
05.2006 - 05.2008
- Processed refunds on credit balances to maintain positive account relationships
- Expedited resolutions to correct customer problems and complaints
- Processed invoice payments and recorded information in account database
- Performed administrative tasks such as copying, scanning and mail sorting on daily basis
- Expedited payments by verifying accuracy and currency of payer information
- Submitted claims to insurance companies.
Cash Posting Specialist
Jobnet
11.2005 - 05.2006
- Converted physical documents via scanning into electronic files and images
- Utilized various scanning hardware, computer programs and applications to scan files and documents
- Reviewed electronically scanned document images to verify accuracy
- Processed and sent invoices, adjustments and credit memos to customers
- Contacted insurance providers to verify insurance information and obtain billing authorization
- Investigated and resolved issues to maintain billing accuracy
- Calculated discounts, percentage allocations and credits
- Scheduled patients and updated insurance, payment history and personal information
- Resolved account variances and reconciled bank statement histories
- Reviewed and analyzed contracts to resolve billing issues with vendors and carriers
- Handled all electronic and manual payments and adjustments, ensuring that data was accurately posted
- Posted payments and sent reviews and denials
- Downloaded, printed and batched electronic funds transfers and remits
- Received payments from insurance providers, including Medicare, and completed immediate processing.
Education
Associates of Arts - Fine Arts
Dallas Community College
Dallas, TX05-2025
Bachelor of Business Administration - Business Administration
Texas A & M
Victoria, TXSkills
- Cultural awareness
- Troubleshooting
- Microsoft Office
- Team building
- Critical thinking
- Analytical skills
- Multitasking
- Collaboration
- Work ethic
- HIPAA compliance
- Medical terminology
- Claim validity assessment
- Insurance claims management
- Positive attitude
- Inbound and outbound calling
- Case evaluation
- Verbal communication
- Policy interpretation
Recognitions
- I want to thank Martha for going above and beyond for the Team and for helping me to understanding my job and effectively complete my assignments. Martha not only offers to help me to understand but also provided me with the materials needed to complete the work assigned without stress. Thank you!! -Germaine Williams.
- Martha did an outstanding job representing the appeals team on today"s Amerigroup call. she was extremely professional and well prepared. She pushed the rep for info needed in order to resolve the claim. She was quick to point out areas where Amerigroup could be more forthcoming. FANTASTIC WORK! -Leslie Martinez.
- Stellar Job Martha for leading the team in ge ing Recon down to double digits and maintaining it! Impressive and leading the way across the company! Thank You for your leadership.- Natasha Snell
- Martha, Thank you so much for your help on rebills, I appreciate you! -Marina Pierce.
- Thank you Martha for your hard work, dedication, and flexibility while working with Appeals. We couldn't have done this without you! Looking forward to everything you"ll do with the Texas integration! -Sujil Joseph
- Martha, thank you for being an awesome Team Lead and keeping us all on task and consistently meeting our metrics. We would not be able to do this without your amazing organizational skills, dedication, and hard work. Blessed to have you as a part of our Appeals team! -Sujil Joseph
- Martha, thank you for everything you do for the Appeals team! From clearing out our Unworked queues, keeping our Recon numbers lower than any other SSC, and continuing to guide and encourage the team. We truly appreciate your dedication and service to Parallon! - Sujil Joseph
- thank you for keeping things in order and helping when needed. It is very much appreciated.- Jerry Valencia
- Martha - Thank you for embracing the MVP transition and always leading by example!- Valerie Daniel
- Thank you for all you do to make our team the greatest!!!- Jerri Valencia
- Martha is our TL for the Dallas & SA Appeals team. She has gone above and beyond to assist on multiple projects. Specifically, she assisted our Follow Up team on boosting their productivity by providing valuable tips. Martha has a positive aitude and strives for excellence in everything she does!- Sujil Joseph
- Martha - Thank you for all you do for the team!!- Valerie Danie
Timeline
Collections Senior Analyst
Parallon Business Solutions LLC
06.2024 - 06.2025
Senior Appeals Analyst
Parallon Business Solutions LLC
04.2022 - Current
Clinical Appeals Team Lead
Parallon Business Solutions LLC
11.2018 - 04.2022
Top Dollar Account Specialist
Parallon Business Solutions
07.2017 - 11.2018
Collector
Parallon Business Solutions
06.2012 - 07.2017
Medical Reimbursement Specialist
Texas Health Resources Dallas
05.2006 - 05.2008
Cash Posting Specialist
Jobnet
11.2005 - 05.2006
Associates of Arts - Fine Arts
Dallas Community College
Bachelor of Business Administration - Business Administration
Texas A & M