Megan Vest
Chester,VA
Summary
Hard working professional looking to expand her career within Sentara Health Plans. Dynamic background in claims processing, with strong written and verbal skills. A quick learner with an enthusiastic attitude, dedicated to providing contributions and expanding working relationships with internal and external partners. Solution oriented with an eye for detail, striving to achieve great results for the better of self and team.
Overview
17
17
years of professional experience
Work History
Claims Adjuster IV & Subject Matter Expert
Virginia Premier/Sentara Health Plans
07.2024 - Current
- Soley responsible for researching and resolving all Reconsideration Team Escalation tickets (these often involve extensive research, returned to SLT Leadership and the Provider Representative and Network Educator teams) and Claims Recoveries Team ChangeGear tickets (third party audit claims research and reprocessing for SIU and settlement and desk audits for PIU) for all QNXT platform requests and providing daily inventory reports to all invested parties
- Applying refunds to applicable settlement methods for PIU, creating the process for “rollover” tracking for multi-month settlements involving refunds
- Partnering with Finance to work with Conduent/CBAS, a direct third party audit vendor specializing in claims savings, performing the validation of audit findings and claims reprocessing (QNXT)
- Within the past 6 month, partnered on all Optum transplant repricing requests directly with Optum personnel, engaging in biweekly meetings (QNXT)
- As Subject Matter Expert, answering a wide variety of claim processing related questions and current CMS and DMAS rules regarding all claim types for both the Claims Reviews Team and Leadership
- Actively working with CAT Team on DME configuration and processing issues (namely Apria), bridging educational gaps for both Sentara claims processers and Network Educators/Provider Representatives to smooth provider abrasion, working as the main contact for Apria claims resolution for both Claims Review and Production questions
- Continuing to work reconsideration inventory in both SHP MACESS paper reconsiderations and VP MACESS provider portal reconsiderations, often tasked with researching team pended items
- Currently, tasked by Senior Leadership to review all Medicaid coding items for reconsideration review. In the past three weeks, inventory has been reduced from 4k+ items to just under 1k, creating the largest reduction of all lines of business
- In terms of production, monthly scorecard often reflects results of over 200% of goal, with 100% quality each tracked month. Each year since hire with Sentara has driven “Exceeds Expectations” evaluations from multiple Team Coordinators.
Refund Analyst & Subject Matter Expert
Virginia Premier/Sentara Health Plans
03.2019 - 07.2024
- Worked as a team of two to resolve all QNXT refund requests, receiving inventory directly from Finance upload (specifically lines of business MLTSS and DSNP/MAPD)
- Spearheaded several large projects for multi-year claim lookback refunds
- Assisted is tracking for Finance during transition from IDX to QNXT
- Responsible for manual check requests to Finance due to system issues or multiple retractions in conjunction to refunds received
- Continued support to Reconsideration inventory reduction based on business need, and exceeded all departmental goals, receiving extremely high quality scores
Reconsideration Specialist
Virginia Premier/Sentara Health Plans
09.2018 - 03.2019
- Reconsideration Specialist (temp to hire December 2018 – March 2019)
ITS Host Provider Service Representative III/Project Specialist
Anthem Inc.
01.2014 - 01.2018
- Provided excellent service to Virginia providers with questions concerning Blue Card claim questions
- Used all available resources to promptly find resolution for pricing or policy issues between the local and home plans
- Diligently followed up with providers after thorough research concerning claims requiring further attention
- Worked closely manager, operations expert, and contacts in neighboring departments on special projects concerning large quantities of claims needing further research for root billing or system problems to ensure timely and accurate processing. As a result of carefully maintained professional rapport, am currently the single point of contact for several large facility/hospital groups with special claims processing needs.
- Performed to all set departmental standards and achieving 100% quality scores each month
- For 2+ years, responsible for all Blue Card manual keying of claims in error and collaborating with other areas in terms of system fixes needed or trends noticed
- Supported team with rejection, allowance and timely override assistance and a wide variety of training assistance
Pharmacy Technician
CVS Pharmacy
Midlothian, VA
01.2012 - 01.2014
- Greeted each patient as they approached pharmacy and acknowledged that they will be assisted shortly if necessary
- Helped each patient picking up prescriptions by confirming all orders are ready and updated personal information as needed
- Inputted incoming prescriptions and third party insurance information promptly and accurately
- Quickly assisted drive-thru customers who were dropping off or picking up orders
- Resolved insurance rejections for medications and advised patients on how to handle each situation accordingly
- Counted out medication based on each order’s requirements
- Answered incoming calls concerning refills, sent requests to doctors for further refills or prior authorization of medications, and directed callers to the pharmacist as needed
- Placed nightly orders for out of stock medication to outside vendors
- Was the technician-in-charge of flu shot tracking/promotion, and our store exceeded our district’s target
Direct Billing Operations Professional
Travelers Insurance
Richmond, VA
01.2011 - 01.2012
- Answered a wide variety of billing questions pertaining to existing policies of business customers and general guidelines of billing for potential clients (including many high profile companies)
- Followed up on requests made by callers to ensure changes are made promptly and accurately
- Worked side by side with other billing departments to route callers’ needs if reinstatement of a policy is needed
- Made changes to billing cycles and payment plans per customer request
- Worked efficiently with default accountholders by constructing customer payment arrangements as painlessly as possible to ensure their policies stay in effect
- Researched and resolved lost paper statements and inquiries of said bills to ensure there was a clear and concise understanding of each item due
- Thoroughly ensured each caller left call with all questions answered and felt their business and concerns were well managed
Claims Customers Service Representative
Travelers Insurance
Richmond, VA
01.2009 - 01.2011
- Provided first rate customer service in a high volume call center
- Serviced customers through the first report claims process for personal lines (auto, homeowners, and liability)
- Accurately inputted new and edited current information by navigating through multiple systems
- Assisted internal and external callers with questions and issues concerning existing claims and policies
- Analyzed and resolved customer complaints and issues without further escalation
- “Warm transferred” misguided callers to correct department
- Excelled within company quality guidelines and adhered to strict handling times
- Used acute discretion and followed all company policies concerning sensitive company questions and issues
- Technologies: All Microsoft Products
Education
High School Diploma -
Monacan High School
Richmond, VACertificate -
AAPC
Skills
All Microsoft Products
QNXT platforms
MACESS
Timeline
Claims Adjuster IV & Subject Matter Expert
Virginia Premier/Sentara Health Plans
07.2024 - Current
Refund Analyst & Subject Matter Expert
Virginia Premier/Sentara Health Plans
03.2019 - 07.2024
Reconsideration Specialist
Virginia Premier/Sentara Health Plans
09.2018 - 03.2019
ITS Host Provider Service Representative III/Project Specialist
Anthem Inc.
01.2014 - 01.2018
Pharmacy Technician
CVS Pharmacy
01.2012 - 01.2014
Direct Billing Operations Professional
Travelers Insurance
01.2011 - 01.2012
Claims Customers Service Representative
Travelers Insurance
01.2009 - 01.2011
High School Diploma -
Monacan High School
Certificate -
AAPC