Qiana Beasley
Senior Appeals Specialist
South Euclid,Ohio
Summary
Dedicated insurance professional with history of meeting company goals utilizing consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand. Detail-oriented and versed in researching and resolving complex issues on behalf of policyholders, companies and carriers. Bringing 30 years of expertise in medical insurance.
Overview
30
30
years of professional experience
Work History
Senior Appeals Specialist
Medical Mutual Of Ohio
Cleveland, Ohio
11.2014 - 03.2022
- Maintained confidentiality of patient records and health statuses.
- Checked documentation for accuracy and validity on updated systems.
- Researched the patient's Certificate of coverage to determine if the requested service is eligible for benefit consideration based on the employers plan benefits.
- Requested medical records from hospital's & physician's offices, then complied those records with the patient's written request and submitted them to the care management team for review.
- Utilized word templates to create written notification of medical & benefit appeal outcomes that included corporate medical policy/Certificate language.
- Analyzed requests for external review, complied appeal requests corporate medical policies, Certificate of coverage & medical records and submitted those requests to the external review organizations in accordance with state and federal guidelines.
Senior Customer Service Representative II
Medical Mutual of Ohio
Cleveland, Ohio
04.1998 - 11.2014
- Provide high level of service that contributed to corporate sales efforts to retain existing accounts and attain new accounts
- Receive and investigate inquiries and claims adjustments
- Respond to telephone, walk-in and written inquires from subscribers, providers and group representatives
- Research inquiries to completion
- Assist with special projects as needed
- Assist management in resolving customer service and system issues
- Detailed knowledge of other departments (i.e
- COB, Marketing, Membership, and Medical Review)
- Trained new Claims and Customer Service Representatives on department policies and procedures.
Associate Claims/Customer Service Representative
Medical Mutual Of Ohio
Cleveland, Ohio
05.1997 - 04.1998
- Processed claims from receipt to completion utilizing TOPPS, AIH and other automated processing systems
- Provided guidance and assistance to management to ensure efficiency regarding claims processing procedures
- Organized work and monitored progress in the attainment of specific unit & department or division goals
- Provided technical assistance as required
- Conducted research and performed corrective action as necessary to achieve disposition of claim/inquiry problems.
Customer Care Representative/Care Management
Medical Mutual Of Ohio
Cleveland, Ohio
09.1995 - 05.1997
- Investigated and analyzed demographic information regarding inpatient and outpatient surgery stays
- Responded to telephone inquiries from Subscribers, Physicians, Hospitals, and Group Representatives
- Maintained a strong knowledge of all lines of business policies and procedures
- Answered high production of customer service calls
- Collaborated with internal departments (Provider Inquiry, Customer Care and Marketing) to resolve inquiries
Coordination of Benefits/Worker’s Compensation
Medical Mutual Of Ohio
Cleveland, Ohio
11.1991 - 09.1995
- Sorted and distributed heavy volume of incoming office mail
- Utilized CTR to update subscribers C.O.B and Worker's Compensation status in the Corporate data base
- Documented positive C.O.B/WC case information and forwarded to the appropriate areas for claim adjustment & processing.
Education
High School Diploma -
Glenville High School
Cleveland, Ohio 09.1989 - 5 1992
Skills
Insurance coverage verification
Prior authorization processing
Understanding of medical terms
Excellent administrative abilities
Documentation abilities
Reporting skills
Insurance industry experience
Data integrity
Patient contact
Collaborative relationships
Good Telephone Etiquette
Critical Thinking
Attention to Detail
Decision-Making
Self-Motivated
Ohio Notary Public
A responsible person appointed by state government to witness the signing of important documents and administer oaths.
Timeline
Senior Appeals Specialist
Medical Mutual Of Ohio
11.2014 - 03.2022
Senior Customer Service Representative II
Medical Mutual of Ohio
04.1998 - 11.2014
Associate Claims/Customer Service Representative
Medical Mutual Of Ohio
05.1997 - 04.1998
Customer Care Representative/Care Management
Medical Mutual Of Ohio
09.1995 - 05.1997
Coordination of Benefits/Worker’s Compensation
Medical Mutual Of Ohio
11.1991 - 09.1995
High School Diploma -
Glenville High School
09.1989 - 5 1992