Nikitia Marshall
San Jose,CA
Summary
Results-driven Appeals Specialist with extensive experience at Kaiser Permanente, excelling in claims processing and regulatory compliance. Proven track record in training and mentoring staff while maintaining strict adherence to HIPAA regulations. Strong investigative skills and a commitment to continuous learning ensure effective resolution of complex appeals and enhanced team collaboration.
Overview
19
19
years of professional experience
Work History
Seniors Appeals Specialist/Appeals Specialist ll
Kaiser Permanente
Oakland, CA
09.2010 - Current
- Processed out-of-plan claim appeals within regulated time frames of five days for acknowledgments and 30 to 60 days for resolutions.
- Reviewed and verified payment discrepancies for Medicare out-of-plan claims.
- Coordinated with the Claims Department’s Research and Resolution unit on payment issues.
- Ensured compliance by reviewing settled insurance claims against company practices and procedures.
- Accurately identified errors and re-filed denied claims received from the Claims Department.
- Evaluated accuracy of claims, focusing on provider charges, service dates, and patient identification.
- Trained new staff on appeals processes and maintained current knowledge of relevant laws and regulations.
Appeals Specialist
Kaiser Permanente
Oakland, CA
12.2008 - 08.2010
- Reviewed and analyzed commercial claims, identifying denied, approved, or partially approved statuses.
- Verified proper application of payment contracts and discounts for out-of-plan claims.
- Triaged incoming member correspondence to ensure timely responses.
- Processed claim grievances within regulatory time frames, acknowledging within five days and resolving within 30 days.
- Streamlined Three River's contract and desktop procedures for balance billing.
- Adhered strictly to federal and state guidelines for information release.
- Acquired insurance authorizations for physician-ordered procedures and tests.
- Ensured compliance with HIPAA regulations in handling patient information.
Department Secretary / Department Clerk
Kaiser Permanente
Oakland, CA
03.2007 - 12.2008
- Triaged all member correspondence efficiently to address inquiries promptly.
- Handled confidential information with discretion and integrity.
- Coordinated functions for a team of twelve employees, enhancing overall productivity.
- Maintained detailed administrative processes to ensure accuracy and efficiency.
- Validated out-of-plan claims in the CATS system, including member appeals.
- Assigned appeals to five commercial specialists for timely resolution.
- Verified and logged appeals in theCIWRS system for daily member inquiries.
- Organized weekly grievance review meetings with regulatory representatives, serving as liaison between departments.
- Processed confidential patient information with integrity and discretion.
Education
Associates Degree - Healthcare Administration and Management
DeVry
Chicago, IL01.2022
Certificate of Completion - Medical Administrative Assistant
ROP
Redwood City, CA, USA01.2006
Certificate of completion - Hospital Coding and Billing
ROP
Redwood City, CA, USA01.2006
High School Diploma - General Education
Prospect High School
Saratoga, CA, USA01.1999
Bachelor of Arts - Business Administration
Colorado Technical University
Colorado Springs, COSkills
- Appeal validation
- Claims processing
- Claims adjudication tracking
- Claims appeal procedures
- Health connect
- UB-04 and HCFA 1500 billing forms
- Microsoft Word
- Excel
- Epic hyperspace system
- Medical terminology
- Valued team player
- Thrives under pressure
- Maintain case processing compliance
- Fast learner
- HIPAA compliance
- Maintains strict company policies
- Customer relationship management
- Team collaboration
- Training and mentoring
- Appeals process proficiency
- Insurance policies
- Continuous learning mindset
- Coverage determination
- Strong investigative skills
- ICD-10 coding
- CPT and HCPCS coding
- Regulatory compliance
- Appeals management
Accomplishments
- Process Implementation, Facilitated the implementation of the desktop procedure for Three Rivers balance bill appeals for appeals claims processed thru the commercial line of business.
- Research, Investigate any necessary information for status of non-contract provider appeals such as approved, denied or dismissed appeals.
- Data Preparation, Prepare Medicare appeal packets for Independent Review Entity (Maximus Federal Services), review regulations, benefits and fees/services justification.
- Reporting, Maintained Medicare ambulance provider appeal status reports to provide management with updated status information for the director reports.
Timeline
Seniors Appeals Specialist/Appeals Specialist ll
Kaiser Permanente
09.2010 - Current
Appeals Specialist
Kaiser Permanente
12.2008 - 08.2010
Department Secretary / Department Clerk
Kaiser Permanente
03.2007 - 12.2008
Associates Degree - Healthcare Administration and Management
DeVry
Certificate of Completion - Medical Administrative Assistant
ROP
Certificate of completion - Hospital Coding and Billing
ROP
High School Diploma - General Education
Prospect High School
Bachelor of Arts - Business Administration
Colorado Technical University