CHANIKIA RICHARDSON
Houston
Summary
Results-driven and adaptable healthcare professional with proven expertise in benefits administration, hospital claims management, customer service, and administrative operations. Analytical and detail-oriented Healthcare Reporting Analyst with extensive experience in claims management, revenue reimbursement, contract administration, and data-driven decision support. Skilled in extracting, analyzing, and interpreting large data sets using Excel, SQL, and healthcare platforms such as FACETS to identify trends, optimize processes, and improve operational performance. Proven ability to collaborate across departments to resolve complex issues, ensure regulatory compliance, and support strategic initiatives. Adept at developing reports, dashboards, and performance metrics that enhance transparency and drive continuous improvement. Committed to delivering accurate, actionable insights that support customer satisfaction and efficient revenue cycle operations.
Overview
8
8
years of professional experience
Work History
Claims Representative II
ANTHEM, INC.
Virginia Beach
01.2021 - Current
- Analyzed healthcare claim data to identify trends, payment discrepancies, and root causes of reimbursement issues; developed actionable insights to improve processing accuracy and efficiency.
- Utilized daily, weekly, and ad hoc reports to monitor claim status, pricing operations, and compliance with Medicaid and Medicare regulations.
- Led the management of Medicaid facility and DME manual pricing claims, ensuring data accuracy, regulatory compliance, and timely submissions.
- Conducted quality assurance checks on processed claims and supporting data, verifying alignment with provider contracts, benefit rules, and internal policy standards.
- Collaborated with cross-functional teams to resolve complex claims issues and streamline workflows; provided data-driven recommendations that enhanced system performance.
- Utilized internal platforms such as FACETS, MACESS, and Claims Workstations to extract, validate, and manage claims-related data.
- Supported the development and refinement of claims procedures through participation in focus groups and performance reviews, contributing data-backed insights.
- Maintained accurate and organized claim records, ensuring compliance with HIPAA and federal/state regulations.
- Investigated claims anomalies and inconsistencies using structured analysis; presented findings to leadership for process improvement consideration.
- Contributed to trend analysis initiatives by identifying emerging issues, proposing reporting enhancements, and supporting strategic planning efforts
Claims Representative I
ANTHEM, INC.
Virginia Beach
01.2020 - 01.2021
- Provided analytical support to the Provider Appeals department by processing and resolving provider disputes and appeals in alignment with Medicare/Medicaid guidelines.
- Collected and validated critical data to generate accurate documentation and reports used for tracking appeal outcomes, denial patterns, and operational metrics.
- Conducted trend analysis on denial/payment variances and presented insights to management, leading to targeted training opportunities and corrective action plans.
- Performed in-depth research and analysis of provider appeals, including medical record reviews and compliance checks, to ensure accuracy and fairness in resolution.
- Ensured strict adherence to statutory requirements and internal policies while addressing provider issues and claims adjustments.
- Used systems such as WGS and NEXTGEN to prepare correspondence, arbitrate claims, and analyze appeal data for discrepancies or inconsistencies.
- Developed data-driven strategies to reduce claim denials and payment delays, improving resolution timelines and provider satisfaction.
- Reviewed and verified claim information, ensuring accuracy, completeness, and compliance with federal and internal standards.
- Identified indicators of potential fraud or abuse during the claim review process and escalated findings to appropriate teams.
- Collaborated cross-functionally to resolve complex billing disputes and recommend improvements to reduce systemic claim processing issues.
Patient Access Specialist
CONDUENT
Chesapeake
01.2018 - 01.2020
- Researched, determined, and evaluated patients' insurance coverage/existing financial resources to pay for medication and healthcare services through effective management of high volume of inbound calls.
- Registered eligible patients and healthcare providers, while translating plan rules and analyzing transactions by verifying required documents' conformity with established guidelines.
- Ensured best-in-class customer service via comprehensive evaluations within set timelines and accuracy standards.
- Drove proper rectification and resolution of participant/patient-related issues by closely reviewing incoming forms.
- Performed data entry tasks associated with registrations such as entering demographic data into system database.
- Provided company users with tech support for IT problems and account maintenance.
- Provided technical support to end users via phone calls or online chats.
- Provided ongoing support for users experiencing technical problems with their computers or peripherals connected via the network.
- Provided support during onboarding process including orientation sessions, technical assistance.
- Provided technical support to production teams in order to optimize the use of raw materials.
Administrative Assistant
RELIABLE HEALTH CARE SERVICES, INC.
Alexandria
01.2017 - 01.2018
- Guaranteed smooth running of functions by adeptly managing and executing administrative support functions, including meeting agenda preparation, presentation assistance, calendar management, and vendor relations.
- Responded to patients, providers/staff, and third-party patient/provider POA representatives' concerns, as well as facilitated requests and escalation processes by acting as key POC (Point of Contact).
- Nurtured and strengthened sustainable, trust-based connections with customer accounts by initiating open and interactive communication.
- Headed various payroll and billing functions involving reviewing time sheets, wage compensation, and other data to distinguish and reconcile payroll discrepancies.
- Introduced new hire onboarding process to facilitate all Home Health Aides, including medical staff and nurses' alignment with regulatory guidelines.
- Achieved client satisfaction by describing contract terms for accurate documentation of expected payments in line with customer agreement.
- Contributed to development of training sessions for Customer Support Specialists and improved effectiveness by delivering necessary service information and determining emergent problems faced by customer accounts.
- Finalized re-credentialing applications for commercial insurance, Medicare, and Medicaid, while enabling primary credentialing process with Virginia DMAS CCC+ participating insurance companies.
Education
B.S. - Data Analytics
SNHU
Skills
- Data Analysis & Reporting
Data Research & Analysis
Trend Analysis
Predictive Analytics
Report Generation
SQL Reporting
Data Visualization (Tableau, other tools)
Reporting Tools & Dashboards - Technical Proficiencies
SQL & SQL Database Management
Python & R Programming
ETL Processes
Big Data Technologies
FACETS System
Excel
- Healthcare Operations
Claims Management
Regulatory Compliance (Medicare/Medicaid)
Revenue Reimbursement
Contract Management
Process Optimization & Improvement - Professional Strengths
Analytical Thinking
Cross-functional Collaboration
Effective Communication
Team Leadership
Client/Customer Excellence
Projects
Anthem Marketplace - User Research Support - GCIO FIRE, Create user insights and opportunities for Sydney digital experiences by liaising with User Experience (UX) Research team. Participate in internal research planning sessions with cross-functional teams, including design, product management, and content strategy. Coordinate staffing and development of study participants through vendor partners. Prepare notes during research sessions, while collecting, synthesizing, and analyzing data. Generate reports and share findings in partnership with researchers.
Timeline
Claims Representative II
ANTHEM, INC.
01.2021 - Current
Claims Representative I
ANTHEM, INC.
01.2020 - 01.2021
Patient Access Specialist
CONDUENT
01.2018 - 01.2020
Administrative Assistant
RELIABLE HEALTH CARE SERVICES, INC.
01.2017 - 01.2018
B.S. - Data Analytics
SNHU