Rachquel Marshall
Jacksonville,Florida
Summary
Highly trained professional with a background in verifying insurance benefits and creating appropriate patient documentation. An established Insurance Verification Specialist known for handling various office tasks with undeniable ease.
Overview
23
23
years of professional experience
Work History
Senior Claims Specialist
Amerihealth Caritas
Jacksonville, FL
02.2017 - Current
- Review and adjudicate claims based on provider and health plan contractual agreements and claims processing guidelines
- Follows all internal processes and procedures to ensure activities are handled in accordance with departmental and company policies and procedures
- Maintains production standards as established by management to meet ‘time to pay’ requirements and, in addition, maintains high quality standards
- Independently works on suspended claims daily ensuring claim accuracy
- Upholds confidentiality of claims ensuring no Protected Health Information (PHI) is sent to incorrect provider or facility
- Ensure all High Dollar (HD) urgent claims are paid in timely manner
Appeals Lead Analyst
C2c Innovative Solutions, Inc
06.2015 - 02.2017
- Conducted research using online federal regulations, review Medicare, Medicaid and CMS policy and guidelines to complete accurate and well supported decision
- Provides customer service and researches and responds to inquire received by phone, fax, mail or email timely and accurately
- Initiate, schedule and coordinate reconsideration phone discussions between suppliers and decision makers by coordinating with appellants on schedule adherence and reschedule as needed
- Maintains strict adherence to confidentiality and security policies and procedures
- Participates in special projects and performs other duties as assigned
- Documents and track any Protective Health Information (PHI) to management per Medicare Appeal System (MAS) or Medicare Claims Systems (MCS)
- Managed business and public relationships with business partners
- Tracked production, error trending, develop workflow procedures and take corrective action on appeals system issues
- Completed paperwork, recognizing discrepancies and promptly addressing for resolution
- Participated in continuous improvement by generating suggestions, engaging in problem-solving activities to support teamwork
Reconsideration Analyst
C2c Innovative Solutions, Inc
01.2015 - 06.2015
- Coordinates delivery of re-determination files and reconsideration decisions from external entities
- Builds reconsideration case files from evidence submitted and received and analyzes each case to ensure it meets requirements for valid reconsideration request as mandated by Centers for Medicare and Medicaid Services (CMS)
- Identifies any suspected instances of fraud and/or abuse and immediately inform management of such issues
- Assures compliance with regulatory, contractual and accreditation entities
- Communicates effectively with internal and external customers
- Adapts to needs of internal and external customers
- Submits requests for re-determination files and completed reconsideration and Administrative Law Judge (ALJ) decisions to relevant entities
Interim Supervisor/Senior Lead
Florida Blue
08.1998 - 05.2014
- Responsible for effectively screening and completing series of medical applications for qualified applicants that met eligibility requirements as defined by State/Federal regulations
- Assisted Benefit agents with any customer issues or inquires for first contact resolution
- Researched and resolved to critical inquiries received from Office of Insurance Regulation
- Completed quality/medical review of 200 to 300 individual medical application on a monthly basis
- Developed business requirements for implementing system enhancements for tracking cycle time within departmental guidelines
- Supervised 10-15 agents in Health Insurance Call Center
- Audited calls of agents and provided timely feedback to ensure departmental indicators were achieved
- Collaborated with internal and external departments and entities to ensure daily goals were met
- Served as subject matter for departmental work groups and special projects
- Handled customer complaints and inquiries regarding medical contracts from upper management and Office of Insurance Regulations (OIR)
- Achieved departmental goals by ensuring agents were available keeping average speed of answer (ASA) under 120 seconds
- Enforced daily policies, rules and compliance regulations to ensure security of members data
- Trained and coached benefit agents on adherence and attendance issues
- Developed departmental Standard Operating Procedures (SOP’s) and Desk Operating Procedures (DOP’s)
- Contacted multiple insurance carriers daily to verify and validate type of insurance coverage effective and termination dates
- Developed departmental Standard Operating Procedures (SOP’s) and Desk Operating Procedures (DOP’s)
- Identified deficiencies with team and agents performance weekly by coaching and provided monthly and yearly performance evaluations
- Assisted Florida Blue dedicated agents with inquires regarding policies and benefit plans
- Lead meetings regarding certain trends to ensure frequent errors were addressed and corrected
- Created successful work schedules for each team member to maintain deadlines and fully staff shifts
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows
- Maintained compliance with company policies, objectives and communication goals
Education
MA - Organizational Management
Ashford University
Chandler, AZ04.2013
BS - Business Administration
Jones College
Jacksonville, FL04.2011
Skills
- 15 years of Sales Marketing/Call Center Experience
- 10 years Supervisory Experience
- Excellent problem-solving skills
- Experience in writing and editing health insurance contract language
- Individual, Medicare and Medicaid claim processing and Appeal Experience
- Call Auditing Experience
- Training Experience
- Policy Modifications and Updates
- Insurance policy coverage knowledge
- Claims
- Coverage determination
- Healthcare Common Procedures Coding System (HCPCS)
Affiliations
Former Rufus E. Payne Elementary School Advisory Council President (S.A.C.)
Robert E. Lee High School Advisory Council Board Member (S.A. C.)
Former Workforce Director Florida Blue ENAABLE Diversity Group
AmeriHealth Employee Engagement Committee Member
First Coast Home Owners Association Board Member
Timeline
Senior Claims Specialist
Amerihealth Caritas
02.2017 - Current
Appeals Lead Analyst
C2c Innovative Solutions, Inc
06.2015 - 02.2017
Reconsideration Analyst
C2c Innovative Solutions, Inc
01.2015 - 06.2015
Interim Supervisor/Senior Lead
Florida Blue
08.1998 - 05.2014
MA - Organizational Management
Ashford University
BS - Business Administration
Jones College
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