SUSAN MONTGOMERY
Mt. Juliet,TN
Summary
An organized and motivated individual, eager to utilize time management and organizational skills across diverse settings. Seeking opportunities to enhance abilities while contributing to company growth.
Overview
21
21
years of professional experience
Work History
Provider Data Senior Representative
Cigna Healthcare
Nashville, TN
07.2023 - Current
- Accurately entering and updating provider demographic information, including names, addresses, contact details, NPI numbers, and specialty codes.
- Ensuring provider contracts are accurately reflected in the system, including network participation details.
- Maintaining and updating provider data in management systems.
- Overseeing data quality, resolving complex data issues, and ensuring compliance with regulations related to provider information.
Appeals Senior Processing Representative
Cigna Medicare
03.2016 - Current
- Peer coaching on loading errors of appeals into MedHOK System
- Reviewing of appeals cases to determine who the appellant is and whether there is a denied claim within the QNXT system or denied authorization on file within the MedHOK system
- Internal auditing of Regulatory cases (member and non-contracted appeals) to ensure appeals passed the CMS audit
- Point of Contact within the Intake team when specific direction is needed to review appellant or claim information.
- Loading data from appeal cases into MedHOK based on appellant criteria.
- Labeling all cases that come through MedHOK as Post, Preservice or Expedited and if appellant is a Regulatory (member or non-contracted provider or non-regulatory (contracted providers) within the information that is received.
- Reviewing Provider contracts within QNXT system.
- Routing of Non-appealable issues to appropriate department within Cigna Medicare or outside of company.
- New hire training and staff education of appropriate triage processes.
- Traveling and training staff with 40 or more participants.
- Researching of all misroutes thoroughly within Filebound system.
- Uploading of Maximus Federal Services decisions based on specific criteria into appeals database.
- Direct backup to Intake Team Supervisor.
- Reviewed files, records and other documents to obtain information or respond to.
- Scheduled meetings and coordinated materials to be distributed to attendees.
- Prepared meeting agendas, attended meetings and recorded and transcribed minutes.
Appeals Senior Associate
Cigna Healthspring
12.2012 - 02.2016
- Reviewing and doing a thorough research on incoming appeals from customers and/or providers.
- Gather appropriate criteria to make judgment on appeal from customers and/or providers.
- Making determination on outcome of the appeal.
- Forwarding information claims department for the claim to be adjusted based on it being approved on appeal and to get paid correctly or sending information to Maximus Federal Services based service/claim not being approved on appeal.
- Monitoring claims on approved appeals to ensure that they are paid on a timely manner.
- Developed and deepened relationships with new and existing clients to advance progress and improve business.
- Researched issues and made quick decisions to achieve efficient and effective resolutions.
- Kept calm and applied strong problem-solving and interpersonal skills to resolve conflicts.
FRONT DESK COORDINATOR
STAR PHYSICAL THERAPY
01.2007 - 12.2012
- Intake and routing of inter-office communications
- Scheduling for multiple services and follow up
- Collecting co-pays or co-insurance
- Coordination and verification of benefits and facilitation of prior authorization
- Data entry into monitoring system
PHARMACY TECHNICIAN
ST. THOMAS HOSPITAL
01.2004 - 01.2007
- Filling and delivering medication to Pyxis machines throughout the hospital
- Assisting in monitoring medication for patients within the hospital
- Preparation of narcotic “bags” for surgery
- Training new hires for the pharmacy
Education
DIPLOMA -
Mount Juliet High School
05.1999
Skills
- Staff Training
- Customer Service
- Productivity & Performance Enhancement
- Strong Communication Skills
- Strong Decision-Making Skills
- Self-Motivator
- Data Entry
- Microsoft Office
- MedHOK
- Reliable & Trustworthy
- Good Work Ethic
- Critical Thinking
Timeline
Provider Data Senior Representative
Cigna Healthcare
07.2023 - Current
Appeals Senior Processing Representative
Cigna Medicare
03.2016 - Current
Appeals Senior Associate
Cigna Healthspring
12.2012 - 02.2016
FRONT DESK COORDINATOR
STAR PHYSICAL THERAPY
01.2007 - 12.2012
PHARMACY TECHNICIAN
ST. THOMAS HOSPITAL
01.2004 - 01.2007
DIPLOMA -
Mount Juliet High School
Similar Profiles
Sweta S IyerSweta S Iyer
Manager- Human Resource Business Partner at Cigna HealthcareManager- Human Resource Business Partner at Cigna Healthcare
Theresa (Terri) HughesTheresa (Terri) Hughes
Product Development Lead Analyst/Product Development Consultant at Cigna HealthCareProduct Development Lead Analyst/Product Development Consultant at Cigna HealthCare
JASON PICKETTJASON PICKETT
Sr, Business Analyst at Cigna HealthcareSr, Business Analyst at Cigna Healthcare