Nichola Carty Tomlinson
MI
Summary
Experienced professional with over 20 years in healthcare administration, specializing in medical claims analysis, claims management, and healthcare configuration. Proven expertise in Medicare, Medicaid, Commercial and Liability Insurance, UAT testing, resolving appeals and grievances, and vendor relationship management. Strong background in medical coding, provider contract management, and benefit adjudication. Adept in managing complex claims, streamlining processes, and improving operational efficiency. Highly skilled communicator and project coordinator with a focus on delivering accurate, timely, and compliant claims processing.
Overview
19
19
years of professional experience
Work History
Configuration Analyst
Curative HR LLC
05.2024 - 12.2024
- Analyzed and resolved pending claims from various sources in a timely manner, ensuring compliance with insurance principles.
- Collaborated with team members to validate and update default benefits, ensuring accurate adjudication of medical claims.
- Developed and implemented provider contract payments, contributing to streamlined claims management processes.
- Created and managed provider tax entities, suppliers, practitioners, and roles, ensuring accurate provider data handling.
- Reviewed and validated provider contracts, ensuring proper benefit adjudication and consistency across claims.
- Reviewed and updated individual contract agreements to reflect accurate benefit structures and terms.
Claims Implementation Analyst
Ikasystems/Emerging Markets-Advantasure
06.2016 - 03.2024
- Acted as a subject matter expert for user acceptance testing (UAT) of medical claims processing, identifying and addressing configuration, claims, benefit and eligibility issues.
- Analyzed, reported, and maintained UAT testing cycles, ensuring thorough validation of claims workflows and processes valid.
- Reviewed, validated and tested BlueCard home and host beneficiary and claims.
- Communicated with product owners, offshore teams, vendors, and clients to ensuring proper documentation and training.
- Developed and refined medical policy papers, Medicare standard letters, and Explanation of Benefit (EOB) documents.
- Recommended pricing limits and variables on NOS or status C codes.
- Performed quality analysis of claims testing, system readiness of positive and negative results.
- Provided assistance and advice on escalated issues, collaborating with recovery teams and reviewing CMS transmittals and Optum edits.
Appeals and Grievances Analyst
UST Health
03.2023 - 02.2024
- Analyzed both verbal and written appeals and grievances, ensuring proper resolution.
- Communicated via calls, emails, faxes and mail regarding case statuses.
- Maintained the integrity of the appeals and grievances process from start to finish, ensuring thorough documentation.
- Established communication channels with providers, members, ensuring all necessary medical records and documents were obtained.
- Applied appropriate determinations based on policy, resolving appeals and preparing written presentations for higher-level appeals.
Claims Project Analyst
Health Alliance Plan
02.2006 - 06.2016
- Managed and provided centralized medical coding support across departments, ensuring accurate coding for claims.
- Functioned as a project coordinator for McKesson ClaimsXten code editing rules, ensuring accurate claims processing.
- Worked directly with providers to resolve billing issues, negative balances, and audit discrepancies, improving claims outcomes.
- Collaborated with recovery groups to adjust claims as needed, ensuring proper coordination and compliance with medical policies.
- Supported billers, TPA's, hospitals, private practices, clients with specialize contracts and vendors.
- Investigated and reconciled claims billing issues, ensuring timely and accurate claim resolutions.
Education
Master of Science - Administration – Concentration in Health Science Administration
Central Michigan University
Southfield, MIBachelor of Science - Administration – Concentration in Healthcare
University of Phoenix
Southfield, MICertificate of Professional Coders -
American Academy of Professional Coders (AAPC)
Skills
- Excellent communication
- Customer service
- Negotiation skills
- Medical claims management
- UAT testing
- Knowledge of Medicare
- Medicaid
- Commercial Insurance
- Medical coding proficiency
- Implementation specialist
- XML
- JAVAScript
- Visual Basic
- HTML
- Appeals and grievances resolution
- Provider contract management
- Benefit adjudication
- Accounting skills
- Financial skills
- Analytical skills
- Organizational skills
- Project coordination skills
- Adaptability
- Teamwork
- Microsoft Office Suite
- Claims management systems
Timeline
Configuration Analyst
Curative HR LLC
05.2024 - 12.2024
Appeals and Grievances Analyst
UST Health
03.2023 - 02.2024
Claims Implementation Analyst
Ikasystems/Emerging Markets-Advantasure
06.2016 - 03.2024
Claims Project Analyst
Health Alliance Plan
02.2006 - 06.2016
Bachelor of Science - Administration – Concentration in Healthcare
University of Phoenix
Certificate of Professional Coders -
American Academy of Professional Coders (AAPC)
Master of Science - Administration – Concentration in Health Science Administration
Central Michigan University
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