Siera Stephenson
South Elgin,IL
Summary
Meticulous healthcare specialist with over 8 years of managed care, medical claims processing, member services, and provider relations. Currently employed as a Senior Service Specialist at WellSense Health Plan with real-time experience in issue resolution, regulatory compliance (HIPAA, CMS, MassHealth) and interdisciplinary coordination. Excellent communicator with the ability to concisely explain complicated policy decisions at every level. Strong project management skills to effectively manage the volume and flow of sensitive documentation while monitoring departmental action levels and overseeing outcomes. Proven ability to support Appeals and Grievance processes and procedures. Presently seeking to utilize my knowledge and experience to transition into a formal Appeals & Grievances role with an organization working toward a mission of "Helping People Live Healthier Lives".
Overview
7
7
years of professional experience
1
1
Certification
Work History
Senior Service Specialist
Wellsense Health Plan
01.2023 - Current
- Investigate and resolve complex member and provider issues related to benefits, prior authorizations, and denied claims, ensuring alignment with CMS, MassHealth, and internal policy.
- Support members through the complaint and appeal processes by explaining coverage determinations and rights, with a focus on regulatory compliance and service excellence.
- Collaborate with enrollment, clinical, and grievance teams to ensure accurate member records and timely resolutions.
- Draft accurate documentation for issue tracking, case summaries, and interdepartmental communication in adherence to NCQA standards.
- Maintain confidentiality and compliance with HIPAA and all internal security protocols.
- Identify trends in recurring issues and contribute to process improvement discussions.
Member Service Representative
Comcast
07.2022 - 01.2023
- Maintained accurate customer records while educating clients on billing systems and troubleshooting service-related issues.
- Utilized internal data systems to input service changes, verify account information, and escalate technical issues.
- Identified recurring system errors and reported data trends to improve service resolution efficiency.
Customer Service Supervisor
UPA
12.2019 - 04.2022
- Oversaw daily data operations and implemented standardized procedures that improved record accuracy and response time.
- Conducted quality audits on team entries and claims support documentation, reducing errors and improving compliance.
- Collaborated with IT and operations to update system workflows and enhance reporting capabilities.
- Trained and mentored staff, promoting team engagement and ensuring accuracy in reviewing invoices and handling inquiries.
Team Lead
UPA
04.2018 - 12.2019
- Managed data accuracy and consistency during client transitions, helping onboard large volumes of client data with minimal discrepancies.
- Led account reviews to ensure integrity of service and claims records, resolving issues quickly through root-cause analysis.
- Trained and mentored staff on data handling best practices and internal system usage.
Education
Bachelor Of Applied Arts And Science - Data Science
University of Phoenix
Online10-2027
Skills
- Appeals & Grievances Coordination
- CMS, MassHealth, NCQA Compliance
- Claims Processing & Dispute Resolution
- Member & Provider Relations
- HIPAA Compliance & Confidentiality
- Workflow Optimization & Quality Assurance
- Health Insurance Policies & Procedures
- Microsoft Office Suite (Excel, Word, Outlook, PowerPoint
- Conflict Resolution & Communication
- Strong Verbal & Written Communication Skills
Certification
- HIPAA Compliance Training
- Ongoing training in health plan processes, claims processing, and provider relations.
Timeline
Senior Service Specialist
Wellsense Health Plan
01.2023 - Current
Member Service Representative
Comcast
07.2022 - 01.2023
Customer Service Supervisor
UPA
12.2019 - 04.2022
Team Lead
UPA
04.2018 - 12.2019
Bachelor Of Applied Arts And Science - Data Science
University of Phoenix
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