Tamala Smith
Raleigh,NC
Summary
Experienced Appeals Specialist with a proven track record at EviCore Healthcare, excelling in claims investigation and appeals process proficiency. Recognized for strong analytical skills and effective communication, achieving successful outcomes through meticulous documentation and collaboration. Committed to continuous learning and maintaining HIPAA compliance while managing multiple priorities efficiently.
Overview
18
18
years of professional experience
Work History
Appeals Specialist
EviCore Healthcare Formerly Care Core National/ Cigna Group
11.2019 - 10.2025
- Assisted in reviewing appeals documentation for accuracy and completeness.
- Researched policies and regulations relevant to appeal processes.
- Participated in training sessions to enhance understanding of appeal procedures.
- Collaborated with cross-functional teams to gather necessary documentation and evidence to support the appeals process.
- Achieved successful appeal outcomes by meticulously reviewing and analyzing claim denials, identifying errors, and presenting persuasive arguments.
- Maintained strict confidentiality of patient information in accordance with HIPAA regulations.
- Managed multiple priorities simultaneously while maintaining attention to detail and meeting deadlines under pressure.
- Verified client information by analyzing existing evidence on file.
- Maintained confidentiality of patient finances, records, and health statuses.
- Evaluated clinical documentation for compliance with regulatory standards and best practices.
- Reviewed medical records to ensure accurate coding and billing practices.
- Collaborated with healthcare providers to clarify documentation discrepancies.
- Adhered to strict timelines for case completion while maintaining a high level of accuracy and attention to detail during the review process.
- Determined and authorized services for patients in accordance with guidelines and regulations.
- Built trust among team members by consistently demonstrating professionalism, integrity, and commitment to excellence throughout the clinical review process.
- Ensured compliance with regulatory standards through meticulous documentation and timely reporting of clinical review findings.
- Managed caseload efficiently while maintaining strict confidentiality of sensitive information per HIPAA regulations.
- Reviewed and documented relevant information into data system applications.
- Strengthened professional development with ongoing education in disease management, treatment protocols, and emerging trends in nursing practice.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
- Evaluated patient histories, complaints, and current symptoms.
Senior Appeal Specialist/Utilization Review Nurse
QualCare, Inc./ Cigna Group
10.2009 - 11.2019
- Managed appeals process for claims, ensuring compliance with regulatory requirements and company policies.
- Analyzed complex case files to identify discrepancies and formulate effective responses to appeal requests.
- Trained new staff on best practices for appeals management, fostering a culture of continuous learning and efficiency.
- Implemented tracking systems to monitor appeal progress, increasing visibility and accountability across departments.
- Reviewed and interpreted policy guidelines to provide accurate recommendations on disputed claims, enhancing overall accuracy in resolutions.
- Collaborated with cross-functional teams to gather necessary documentation and evidence to support the appeals process.
- Achieved successful appeal outcomes by meticulously reviewing and analyzing claim denials, identifying errors, and presenting persuasive arguments.
- Consistently met or exceeded performance metrics, demonstrating a strong understanding of the claims review process and an unwavering commitment to achieving positive results for clients.
- Acted as a departmental resource on appeals matters.
- Maintained high levels of accuracy in all written correspondence, ensuring clear communication with relevant stakeholders during the appeals process.
LPN
Complete Care at Park Place
04.2008 - 12.2009
- Administer medications and treatments according to established protocols and patient care plans.
- Monitor vital signs and report significant changes to healthcare team for timely interventions.
- Collaborate with nursing staff to develop individualized patient care strategies for optimal recovery.
- Educate patients and families on health management, medication adherence, and preventative care practices.
- Maintain accurate patient records using electronic health record systems to ensure compliance and continuity of care.
- Cared for wounds, provided treatments, and assisted with procedures.
- Assisted with admissions, appointments, transfers, and discharges.
- Demonstrated excellent technical skills in wound dressing changes, IV therapy administration, catheter insertion, and other routine nursing procedures.
- Comforted and counseled patients and families throughout care process.
- Provided compassionate palliative care for terminally ill patients while supporting their emotional needs during end-of-life stages.
- Used aseptic techniques to provide sterilized wound care and dressing applications.
- Maintained a safe and therapeutic environment for patients through effective risk assessment and crisis intervention strategies.
- Delivered updates in patient status to charge nurse, recording changes in medical records.
- Offered immediate assistance in emergency and routine paging situations to evaluate needs and deliver care.
- Assisted with feeding and monitored intake to help patients achieve nutritional objectives.
- Assisted physicians with diagnostic testing and procedural support for optimal treatment decisions.
- Coordinated patient transfers to other facilities.
- Helped long-term care residents with bathing, dressing, feeding, and other daily living activities.
- Implement infection control measures in accordance with hospital policies to ensure a safe environment for patients and staff.
- Gathered lab specimens, ordered testing, and interpreted results to diagnose patients.
- Ensured regulatory compliance by adhering to infection control protocols and maintaining accurate documentation of patient data.
Education
No Degree - Associates Degree in Nursing
Middlesex County College
Edison, NJLPN - Licensed Practical Nursing/Licensed Vocational Nur
Piscataway Vocational Technical School
Piscataway, NJ03-2008
Skills
- Effective communication
- Professionalism and ethics
- Continuous learning mindset
- Strong analytical skills
- Insurance policies
- Appeals process proficiency
- Teamwork and collaboration
- Customer service
- Time management
- Attention to detail
- Claims investigation
- Multitasking Abilities
- Reliability
- Adaptability and flexibility
- Computer proficiency
- HIPAA compliance
- Organizing and prioritizing work
Timeline
Appeals Specialist
EviCore Healthcare Formerly Care Core National/ Cigna Group
11.2019 - 10.2025
Senior Appeal Specialist/Utilization Review Nurse
QualCare, Inc./ Cigna Group
10.2009 - 11.2019
LPN
Complete Care at Park Place
04.2008 - 12.2009
No Degree - Associates Degree in Nursing
Middlesex County College
LPN - Licensed Practical Nursing/Licensed Vocational Nur
Piscataway Vocational Technical School