Summary
Overview
Work History
Education
Skills
Timeline
Generic

Melva Victorian

Metairie,United States

Summary

Experienced analyst with a strong background in policy development, workflow enhancement, and data analysis. Demonstrated expertise in regulatory compliance, interdisciplinary collaboration, and quality assurance. Recognized for ability to create and implement effective utilization management policies and procedures. Committed to fostering a cooperative work environment that drives organizational success.

Overview

21
21
years of professional experience

Work History

Care Worker (Utilization Management/ Case Management Support)

Magellan Health
01.2024 - Current
  • Prepared reports summarizing utilization patterns, outcomes, and quality measures
  • Analyzed data to identify areas where improvement initiatives could be implemented
  • Monitored compliance with regulatory requirements related to utilization management activities
  • Completes denial letters for services denied by Medical Director
  • Generates and prints denial letters for mailing
  • Provides feedback to ensure denials are handled according to CMS standards
  • Collaborates with other departments to produce letters for services denied in their respective units
  • Identifies opportunities to enhance workflow and offers solutions
  • Answers and routes incoming calls from providers, medical groups, and others verifying referral status
  • Developed and implemented utilization management policies and procedures
  • Reviewed claims for accuracy prior to submission for payment processing
  • Reviewed appeals from members or providers regarding denied services or treatments
  • Analyzed large datasets with statistical methods and software programs
  • Analyzed utilization patterns and quality measures to identify improvement areas, enhancing decision-making processes and operational efficiency
  • Meticulously reviewed and processed denial letters, ensuring compliance with CMS standards and collaborating across departments for comprehensive coverage.

Utilization Management Specialist

Elevance Health
09.2022 - 01.2024
  • Prepared reports summarizing utilization patterns, outcomes, and quality measures
  • Analyzed data to identify areas where improvement initiatives could be implemented
  • Monitored compliance with regulatory requirements related to utilization management activities
  • Completes denial letters for services denied by Medical Director
  • Generates and prints denial letters for mailing
  • Provides feedback to ensure denials are handled according to CMS standards
  • Collaborates with other departments to produce letters for services denied in their respective units
  • Identifies opportunities to enhance workflow and offers solutions
  • Answers and routes incoming calls from providers, medical groups, and others verifying referral status
  • Developed and implemented utilization management policies and procedures
  • Reviewed claims for accuracy prior to submission for payment processing
  • Reviewed appeals from members or providers regarding denied services or treatments
  • Analyzed large datasets with statistical methods and software programs
  • Analyzed utilization patterns and quality measures to identify improvement areas, enhancing decision-making processes and operational efficiency
  • Meticulously reviewed and processed denial letters, ensuring compliance with CMS standards and collaborating across departments for comprehensive coverage.

Medical Bill Review Rep

Louisiana Workers Compensation
08.2014 - 08.2022
  • Assisting providers with billing issues, claims, appeals, and payments
  • Contacting providers, claimants, and policyholders' day to day
  • Manually processing bills and also scanning the bills into the system
  • Assisting with the medical coding of bills, HIPAA guidelines and PHI
  • Acting as a liaison for the policyholder, provider and the claim rep
  • Following the policy and procedures for workers comp insurance and Medicare guidelines
  • Providing excellent customer service to the customers
  • Handling the customer's issues in a timely manner
  • Educating the providers on how to bill their claims and the timely filing process
  • Case Management provider referral, discharge planning coordination and follow up of workers compensation injury claims
  • Educate providers, members and community resources on available support services, policies and procedures related to referrals, authorizations, claims submission, web site usage and related topics
  • Analyzing written reports, such as medical records and legal documentation
  • Experience with disputed and litigation worker's compensation claims
  • Strong written and oral communication skills, analytical, investigative, and negotiation skills
  • Advanced knowledge of coverage, liability, and complex claims handling procedures
  • Full working knowledge of claims operations and procedures
  • Maintains knowledge of required lines of business, changes to applicable company policies/procedures, recent laws, and regulations, HCPCS coding, ICD-9 codes, medical terminology and related computer systems to ensure information is current and accurate when providing service to members
  • Provider credentialing and provider contracting
  • Utilized CRM software to track customer interactions, sales, and progress towards targets
  • Compiled and analyzed sales data to identify trends and opportunities for growth
  • Coordinated with logistics and supply chain teams to ensure timely delivery of products.

Provider Relations Rep I

Molina Healthcare
02.2012 - 08.2014
  • Assisting providers with claims, denials, and billing instructions
  • Contacting providers/billers daily to reconcile old accounts
  • Account reconciliation and insurance guideline support of Medicaid service providers
  • Documenting billing information in regards to patient, insurance, and patients' employer encounters
  • Researching and appealing rejected/denied claims
  • Maintained accurate records of all communications with providers including emails, letters, phone calls
  • Streamlined medical bill processing, ensuring compliance with HIPAA guidelines and Medicare regulations while managing complex workers' compensation claims
  • Acted as a liaison between policyholders, providers, and claim representatives, resolving billing issues and educating stakeholders on claim procedures
  • Maintained up-to-date knowledge of HCPCS coding, ICD-9 codes, and medical terminology to provide accurate information and service to members
  • Coordinated provider referrals and discharge planning, optimizing case management for workers' compensation injury claims and improving patient outcomes
  • Partnered with logistics and supply chain teams to ensure timely delivery, while utilizing CRM software to track customer interactions and identify growth opportunities
  • Served as a vital liaison between policyholders, providers, and claim representatives, fostering clear communication and resolving issues promptly
  • Managed provider credentialing and contracting, ensuring compliance with industry standards
  • Analyzed medical records and legal documentation for claim accuracy.

Collection Specialist I (Temp Position)

Cox Communications
01.2011 - 02.2012
  • Attended training sessions to stay abreast of changes in industry regulations related to collections practices
  • Handled incoming calls from customers regarding account status, billing inquiries, payment arrangements
  • Analyzed customer creditworthiness, financial condition, and account history to determine appropriate collection action.

ITS Provider Relations I

Blue Cross Blue Shield of Louisiana
12.2008 - 10.2010
  • Compiled and maintained records of provider contracts, claims processing issues, authorizations, and other related matters
  • Reviewed current trends in reimbursement practices, payer policies, and healthcare regulations to inform decisions related to provider networks
  • Tracked changes in provider enrollment status and updated internal systems accordingly
  • Assisted customers with claims processing and managing medical records
  • Served as an account's receivables/customer service representative
  • Responded to and resolved difficult customer service issues
  • Quickly and effectively solve customer challenges via phone and via e-mail
  • Maintained quality control/satisfaction records, constantly seeking new ways to improve customer service
  • Community outreach and Case Management intervention referral, discharge planning coordination and follow up
  • Assisting members with scheduling appointments and providing them with healthcare assessments, transportation assistance if needed, PCP or specialist selection
  • Provider contracting and provider credentialing.

Customer Relations Representative

Express Agency
01.2005 - 12.2007
  • Analyzed competitor pricing strategies to stay competitive in the marketplace
  • Collaborated with other departments to ensure a seamless customer service experience
  • Actively sought out new sales opportunities by engaging existing customers in conversations about additional products or services they may be interested in purchasing
  • Worked for various companies assisting with customer service
  • Also worked for the Road Home Program by new applications and assisted on status of old applications
  • Also worked for United Healthcare as a remote agent from home
  • Responsible for the most complex customer service issues as a result of exceptional ability to promptly resolve concerns and satisfy customers
  • Answered customer inquiries via telephone, email and social media platforms
  • Compiled weekly and monthly performance metrics related to customer relations activities
  • Analyzed customer feedback data to identify areas of improvement in the customer experience
  • Mentored new employees on procedures and policies to maximize team performance.

Customer Relations Representative II

AT&T
02.2004 - 11.2005
  • Created loyalty programs to reward repeat customers for their patronage
  • Provided product information, pricing and availability to customers
  • Collaborated with other departments to ensure a seamless customer service experience
  • Assisted with billing and relocation of accounts
  • Worked onsite and as a remote agent
  • Provided technical support to customers via phone
  • Ability to train, motivate, and supervise customer service employees
  • Analyzed customer feedback data to identify areas of improvement in the customer experience
  • Processed payments from customers using various payment methods including cash, credit cards, checks
  • Analyzed competitor pricing strategies to stay competitive in the marketplace
  • Developed customized sales plans for individual customers based on their needs
  • Monitored inventory levels of products regularly and placed orders as needed
  • Provided detailed explanations of product features and benefits
  • Acknowledged with the 'Total Quality Customer Service Professional' award.

Education

BSN Business Administration -

Southern New Hampshire University

Skills

  • Policy Development
  • Workflow Enhancement
  • Statistical Analysis
  • Quality Assurance
  • Regulatory Compliance
  • Interdisciplinary Collaboration
  • Data Analysis
  • Project Management
  • Team Leadership
  • Communication Skills
  • Process Improvement
  • Strategic Planning
  • Risk Management
  • Progress Documentation
  • Behavioral Management
  • Incident Reporting
  • HIPAA Compliance
  • Multitasking and Organization
  • Records Management
  • Case Management
  • Medical record-keeping
  • State regulations knowledge
  • Strong Ethics
  • Records Maintenance
  • Time Management
  • Medical Records Management
  • Problem-Solving
  • Verbal and written communication skills
  • Critical thinking abilities
  • Insurance Verification
  • Conflict resolution techniques
  • Records analysis
  • Medicaid knowledge
  • Utilization review
  • Healthcare regulations
  • Quality Improvement
  • Documentation And Reporting
  • Discharge planning coordination
  • Medicare knowledge
  • Medical Coding
  • Claims Investigation
  • Claims Management
  • Claims Evaluation
  • Policy Interpretation
  • Settlement Negotiations
  • Claim Form Analysis
  • File and Record Management
  • Liability Determination
  • Decision-Making
  • Claims Processing
  • Critical Thinking
  • Team Collaboration
  • Policy investigations
  • Litigation Support
  • Healthcare Common Procedures Coding System (HCPCS)
  • Payment Processing
  • Professionalism
  • Analytical Skills
  • Underwriting knowledge
  • Settlement Negotiation
  • Records Review
  • Written Communication
  • Analytical Thinking
  • Policy analysis
  • Denied claims identification
  • Interpersonal Skills
  • Microsoft Office Suite
  • Database Management
  • Report and Records Review
  • Provider relationship management
  • Fee exception negotiations
  • Workflow Analysis
  • Activity diagrams
  • Insurance policy coverage knowledge
  • Risk Assessment
  • Highly motivated
  • Advanced computer skills
  • Caseload Management
  • Medical terminology knowledge
  • Eligibility Determination
  • Data Entry
  • Prior authorization processing
  • Medical Terminology
  • Multitasking
  • Referral management
  • Service Utilization Improvements
  • Epic Systems
  • Utilization Management
  • Care Coordination
  • Program Development
  • Email and Telephone Etiquette
  • Resource Management
  • Case Documentation
  • Quality Assurance Controls

Timeline

Care Worker (Utilization Management/ Case Management Support)

Magellan Health
01.2024 - Current

Utilization Management Specialist

Elevance Health
09.2022 - 01.2024

Medical Bill Review Rep

Louisiana Workers Compensation
08.2014 - 08.2022

Provider Relations Rep I

Molina Healthcare
02.2012 - 08.2014

Collection Specialist I (Temp Position)

Cox Communications
01.2011 - 02.2012

ITS Provider Relations I

Blue Cross Blue Shield of Louisiana
12.2008 - 10.2010

Customer Relations Representative

Express Agency
01.2005 - 12.2007

Customer Relations Representative II

AT&T
02.2004 - 11.2005

BSN Business Administration -

Southern New Hampshire University

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Melva Victorian