Destiney Washington
Healthcare claims professional with extensive experience processing and reviewing Medicaid and Medicare claims in high-volume environments. Skilled in handling complex and non-auto-adjudicated claims, conducting detailed manual reviews, and ensuring accurate application of coverage, coding, and policy guidelines. Experienced in interpreting ICD-10, CPT, and HCPCS coding, resolving claim discrepancies, and managing rework, adjustments, and denials in compliance with CMS regulations and HIPAA standards. Strong background in maintaining accurate documentation, meeting productivity and quality metrics, and supporting efficient claims workflows. Known for analytical thinking, attention to detail, and the ability to navigate claims systems to deliver accurate and compliant outcomes.
Work History
Senior Claims Specialist
1 Year 6 Months- Assisted in reviewing and handling escalated or complex claims cases, providing guidance on proper resolution
- Supported training and onboarding of new team members, sharing best practices for claims review and compliance
- Participated in quality assurance (QA) reviews and audits, ensuring adherence to regulatory and company standards
- Collaborated with providers and internal departments to obtain missing documentation and clarify billing or coding discrepancies
- Monitored and met productivity, accuracy, and quality metrics, consistently maintaining high performance in a high-volume environment
- Identified trends in claim errors and contributed to process improvement initiatives to reduce denials and increase efficiency
- Conducted manual adjudication of claims requiring detailed review of policy provisions, benefits, and authorization requirements
Claims Processor (Healthcare)
1 Year 4 Months- Verified member eligibility, benefits, and coverage limits to determine claim payment or denial outcomes
- Interpreted Explanation of Benefits (EOBs) and claim details to ensure accurate processing and reimbursement
- Researched and resolved claim discrepancies, denials, and rework requests in accordance with CMS and company policies
- Processed adjustments, corrections, and resubmitted claims to ensure accurate payment outcomes
- Maintained detailed claim documentation and notes within internal systems for audit and compliance purposes
- Processed medical claims for Medicaid and Medicare plans, ensuring accuracy, completeness, and compliance with payer guidelines
- Reviewed claims for correct coding (ICD-10, CPT, HCPCS), eligibility, and authorization requirements prior to adjudication
- Analyzed claims that did not auto-adjudicate and performed manual review and resolution based on policy and coverage guidelines