NICOLE ALLISON
Elevance Health
New Port Richey,FL
10
years of professional experience
Seeking the position of Claims Auditor, Managed Care for Cedars Sinai Medical Center. Experienced healthcare claims and billing professional with experience processing professional and facility claims, provider reconsiderations, pre and post Appeals & Grievance process, and prior authorizations. Extensive knowledge of CMS guidelines, ICD-10, CPT, and HCPCS coding principles. Proven ability to analyze claim data, resolve complex issues, ensure regulatory compliance, meet established deadlines and improve operational accuracy. Familiar with audit of adjudicated claims and providing analysis upon error findings.
Work History
Provider Reconsideration Analyst / Claims Representative II
3 Years 7 Months- Investigate provider reconsideration requests involving reimbursement, contractual pricing, coding, and payment accuracy.
- Analyze professional and facility claims using FACETS, Macess, Claims Workstation (CWS), and NextGen.
- Research overpayment and underpayment issues through claim history, pricing methodology, provider contracts, and health plan policies.
- Interpret Medicare Advantage regulations, CMS guidance, and reimbursement policies.
- Collaborate with nurses, medical directors, provider representatives, and third-party vendors on clinically reviewed cases.
- Resolve complex payment issues while meeting quality, productivity, and turnaround standards.
Medical Claims Review Specialist
1 Year 5 Months- Reviewed prior authorization requests for compliance with health plan requirements.
- Investigated claim processing discrepancies and coordinated medical record reviews.
- Ensured compliance with Medicare Advantage guidelines and internal policies.
Appeals and Grievances Coordinator
4 Years 3 Months- Coordinated resolution of member appeals and grievances, ensuring compliance with regulatory standards.
- Analyzed complex case files to identify key issues and develop effective solutions.
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Submitted verbal and written notification to members and providers.
Education
Bachelor of Science - Healthcare Compliance & Regulations
Associate of Science
Timeline
Provider Reconsideration Analyst / Claims Representative II
Elevance Health
01.2023 - CurrentRead More
Medical Claims Review Specialist
WellMed Medical Management
05.2021 - 10.2022Read More
Appeals and Grievances Coordinator
WellCare
11.2016 - 02.2021Read More
Arizona State University
Bachelor of Science from Healthcare Compliance & Regulations
Read More
Pasco-Hernando State College
Associate of Science
Read More