Quesonna Blackmon
Summary
Detail-oriented Healthcare Claims Analyst with over 15 years of experience analyzing, adjudicating, and adjusting medical claims while ensuring compliance with Medicare, Medicaid, commercial payer guidelines, and provider contracts. Extensive experience reviewing Explanation of Benefits (EOBs), processing claim adjustments, analyzing Coordination of Benefits (COB), researching reimbursement discrepancies, resolving appeals, and identifying claim trends. Strong analytical, problem-solving, and communication skills with a proven ability to improve claims accuracy, support operational efficiency, and collaborate across departments in remote environments.
Overview
15
15
years of professional experience
Work History
Claims Examiner
Health Plans Inc
Remote
04.2022 - Current
- Analyze and correct system-generated errors before final claims adjudication.
- Process medical claims according to provider contracts, benefit plans, and company policies.
- Process claim adjustments to ensure accurate reimbursement based on contractual agreements and benefit guidelines.
- Review Explanation of Benefits (EOBs) to validate payments, denials, and claim adjustments.
- Analyze Coordination of Benefits (COB) to determine primary and secondary payer responsibility.
- Research paper and electronic claims to resolve complex claim issues and appeals.
- Communicate with internal departments through email and CSI to ensure accurate provider and reimbursement information.
- Escalate complex claims and system issues to leadership.
- Consistently meet production and quality standards.
Claims Examiner II
Integrated Home Care Services
Remote
03.2021 - 03.2022
- Adjudicated Home Health, Durable Medical Equipment (DME), and Infusion claims according to Medicare, Medicaid, fee schedules, and health plan guidelines.
- Determined claim payments or denials and prepared appropriate correspondence.
- Reviewed provider contracts to ensure reimbursement accuracy.
- Supported provider network updates by validating contract changes and reimbursement rates.
- Collaborated with management to accurately interpret negotiated provider agreements and implement contract changes.
- Recovered overpayments identified through audits.
- Reviewed claims hold reports and reported system issues.
- Maintained exceptional customer service and processing accuracy.
Denials Specialist
Conifer Health Solutions LLC
Remote
02.2020 - 03.2021
- Managed insurance follow-up and collections through payer portals and outbound communication with patients, providers, and insurance companies.
- Reviewed Explanation of Benefits (EOBs) to validate denials, payment variances, and reimbursement accuracy.
- Verified claims adjudication using multiple healthcare systems and payer resources.
- Generated appeals for denied and underpaid claims.
- Identified reimbursement trends and recommended process improvements.
- Maintained detailed documentation of collection activities.
- Managed high-priority and aged accounts while meeting productivity expectations.
EDI Claims Analyst
Health Care District of PBC
Remote
01.2012 - 12.2019
- Analyzed and adjudicated physician, hospital, and DME claims according to health plan guidelines.
- Processed claim adjustments and ensured accurate reimbursement based on provider contracts and benefit plans.
- Reviewed Explanation of Benefits (EOBs) to validate payments, denials, and claim adjustments.
- Analyzed Coordination of Benefits (COB) to determine payer responsibility.
- Processed provider appeals according to contractual agreements and organizational policies.
- Analyzed EDI transaction files to identify and resolve processing errors.
- Investigated reimbursement discrepancies, recreated remittance advices, processed check requests, and coordinated refund reissues.
- Recovered overpayments identified through audits.
- Researched provider contracts to ensure accurate reimbursement rates.
- Developed and analyzed testing scenarios for contract implementations and fee schedule modifications.
- Collaborated across departments to improve claims processing accuracy and compliance with federal and state regulations.
Education
Bachelor of Science - Health Administration
Palm Beach State College
Lake Worth, FL05.2021
Associate of Arts -
Palm Beach State College
Lake Worth, FL05.2019
High School Diploma -
Royal Palm Beach High School
05.2006
Skills
- Medical Claims Adjudication
- Claims Adjustments
- Explanation of Benefits (EOB) Review
- Coordination of Benefits (COB)
- Appeals & Reimbursement Analysis
- Medicare & Medicaid Guidelines
- ICD-9, ICD-10
- UB-04 & CMS-1500 Claims
- Provider Contract Analysis
- EDI Claims Processing
- Payment Variance Analysis
- Claims Auditing & Overpayment Recovery
- Root Cause Analysis
- Microsoft Excel, Word, PowerPoint, Adobe Acrobat, SharePoint
- Customer Service & Cross-Functional Collaboration
Timeline
Claims Examiner
Health Plans Inc
04.2022 - Current
Claims Examiner II
Integrated Home Care Services
03.2021 - 03.2022
Denials Specialist
Conifer Health Solutions LLC
02.2020 - 03.2021
EDI Claims Analyst
Health Care District of PBC
01.2012 - 12.2019
Bachelor of Science - Health Administration
Palm Beach State College
Associate of Arts -
Palm Beach State College
High School Diploma -
Royal Palm Beach High School