ORIYUNNA DENSON
Tampa,FL
Summary
Versatile professional with a diverse background in healthcare admin, known for the adaptability and a proven ability to excel in a fast-paced environments. Skilled in claIms, customer care, grievance, data entry, project management, and problem solving, with a focus on delivering results and driving team success. Im eager to leverage a wide range of experiences to add value in dynamic roles.
Overview
8
8
years of professional experience
Work History
Insurance Verification
Aston Carter
11.2023 - 06.2024
- Verify insurance eligibility and benefits for scheduled services or service being provided
- Accurate calculation of patient’s estimated responsibility for scheduled services
- Determination of authorization/referral requirements according to payor guidelines
- Validation of all authorizations/referrals according to established guidelines
- Determine if scheduled service is medically necessary according to payor guidelines
- Adherence to all documentation standards
- Maintain effective, professional communication with patients, physicians, medical office staff to ensure compliance with identified payor requirements
- Educate patients on insurance benefits and financial responsibility effectively
- Ability to perform all other duties as assigned or requested
- Work/facilitate spread sheets
- Op billing and collecting payments
- HMS, genesys, cerner, Kronos, ecare, Athena
Grievance coordinator
Cigna- Hireright
08.2022 - 09.2023
- Manages Medicare/Medicaid grievances that are presented by the members or their representatives pertaining to the authorization of delivery or clinical and non-clinical
- Works in collaboration with divisions within and outside the organization to resolve issues and complaints in a timely manner
- Screen incoming complaints received orally or in writing, conducting root cause analysis as needed, creating an action plan, coordinating and communicating resolutions, as well as documenting systems in detail with case notes related to Customer grievances with in CMS guidelines
- Make outbound calls to members for clarification or updates on grievance
- Contact providers when additional information is needed
- Intake faxes received from customer service representative on GAD
- Works collaboratively with the Claims, Customer Service, Appeals, and Medical Management Departments
- Toggles through multiple screens/tabs
- Meet daily quota of 30 cases a day
- Create/generate decision letters based upon the complaint made
- KnowledgeXchange, Access2Care, Filebound, MHK, Microsoft word & excel, OneView, Verient, evicore, express scripts, QNXT
Benefit Claim Specialist
Metlife-Tailored Management
01.2020 - 01.2022
- Work under the EDM benefits team and RIS death claims
- Work independently and perform tasks relative to Benefit Claim Services (BCS) processes
- Successfully execute collection attempts of overpaid benefits upon an annuitant or contingent death
- Determine whether an actual overpayment has been made, based upon contract specifications
- Communicate with the estate in order to recoup overpaid benefits
- Perform Thorough Search process in order to locate individuals that holds a liability to pay
- Locate most current address information for individuals to ensure prompt payment of funds
- Accurately and efficiently perform research and process deaths of annuitants/contingents, based upon death reporting
- GPAY, ACE, MICROSOFT EXCEL, XCELYS, SESSION1&2, DAAT, L&N, CASE MANAGER
Senior Claims Adjuster
Chubb
07.2018 - 12.2019
- Processing and hospital/medical claims working within contracted TAT times
- Research, investigate, negotiate, process, adjust and adjudicate medical claims
- Preforming check-work and voiding necessary claims for reprocessing
- Processed claim forms, adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements
- Provided timely customer service to members, providers, billing departments and other insurance companies on the subject of claims
- Making outbound calls to obtain required information for re-consideration or first claims
Claims Specialist
Cognizant
10.2016 - 05.2017
- Provide excellent customer service to the elderly and disabled citizens assisting with benefits and transportation
- Compared members benefits using out of network providers and in network providers
- Identified claim issues and implement solutions
- Distributing special projects and assignments to floor staff in accordance to specific claims
- Resolving all escalated customer issues and following up when appropriate
Education
Associates degree -
SPC College
Saint Petersburg, FL07.2025
Timeline
Insurance Verification
Aston Carter
11.2023 - 06.2024
Grievance coordinator
Cigna- Hireright
08.2022 - 09.2023
Benefit Claim Specialist
Metlife-Tailored Management
01.2020 - 01.2022
Senior Claims Adjuster
Chubb
07.2018 - 12.2019
Claims Specialist
Cognizant
10.2016 - 05.2017
Associates degree -
SPC College
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