Tameshia Hooks
Willingboro,NJ
Summary
Detail-oriented Quality Assurance Auditor adept at developing and maintaining strong industry compliance programs. Hardworking and organized professional with in-depth understanding of evaluation processes and audit procedures. Pursuing new professional challenges with an expanding operation.
Overview
23
23
years of professional experience
Work History
Operations Quality Auditor
AmeriHealth Caritas
10.2022 - Current
- Fully remote work
- Responsible for the timely and accurate review of appeal outcome letters, scheduling letters, enclosure letters and episode audits conducted by the Quality Auditing team
- Performing audits of Intake Coordinators, Appeals and Grievance Coordinators and Nurses, in compliance with the State of Pennsylvania Medicaid contract guidelines
- Develop and implement strategies to address areas of non-compliance
- Organize and participate in workgroups to train new staff
- Observe and report team issues or performance gaps
- Effectively work through assigned projects or workload in partnership with other internal departments
- Collaborate and communicate effectively with teammates and leadership to create and maintain proven process methods
- Establish and help manage communication escalation issues
- Expert in understanding multiple lines of business while ensuring each LOB is processed according to their expectations and compliance guidelines
Document Processing Specialist
Medlogix
12.2020 - 02.2024
- Remote work – Responsible for the verification of all demographic information, provider name and address and code information on HCFA1500 claim forms, UB-04 billing forms and NY State accident reports
- Matching the correct form with the correct claimant and sending it for further processing to either the insurance company or the billing department
- (part-time)
Grievance Appeals Coordinator
AmeriHealth Caritas
08.2021 - 10.2022
- Fully remote work
- Analyze, investigate, and resolve verbal and written claims and authorization grievance/appeals and complaints from providers and members
- Resolve all State inquiries related to complaints, grievances, and appeals
- Review and process member and provider grievances and appeals within federal, state, and organizational regulations and policies and procedures
- Review claim grievance for reconsideration and either approve/deny based on determination level or prepare for medical review presentation
- Prepare cases for medical review as necessary
- Review and determine if claim grievance includes a potential quality or access issue
- Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases
- Serve as liaison between members, provider regulatory agencies and internal staff
- Correspond with key individuals regarding grievance and appeal decisions
- Act as subject matter expert regarding grievances and appeals
- Occasionally required to participate in the Appeals and Grievance Committee meeting
Team Lead/ Field Case Management Coordinator
Medlogix
07.2007 - 10.2020
- Remote work
- Responsible for the general supervision of clerical staff for maintenance of a positive work environment
- Created coverage plans for scheduled and unscheduled absences
- Distributed work among team members as needed
- Coordinated orientation and training for new employees
- Calendar Management, Word Processing of medical reports, Lifetime cost projections and letters
- Handled a very large number of medical records for referrals
- Open/close files and provide updates in Excel
- Proofread reports to ensure accuracy and quality of work product
- Contacted injured workers as well as injured parties regarding automobile accidents to confirm correct demographics
- Contacted family members for injured parties who were incapacitated
- Schedule appointments for injured claimants
- Requests medical office notes from providers
- Respond to inquiries regarding claims
- Maintain expense reimbursements for field case managers
- Process payroll vouchers
- Run monthly reports
- Update time off calendar
- Enter information into re-pricing and Medlogix systems
- Took meeting minutes, assign Workers Compensation and Auto accident referrals to field case managers according to their location and case load
- Contacted attorneys to obtain approval/denial for client contact, send corresponding letters to attorneys and medical providers, contact insurance adjusters for referral details, process Precertification requests
- Order office supplies, process incoming/outgoing mail, occasional front desk coverage and all other clerical duties as needed
Test Administrator
Mercer County Community College
09.2012 - 03.2012
- Responsible for scoring and administering exams (CLEP, computer and distant learning) by distributing test materials, reading directions to students for group exams
- Proctoring to make sure all students are testing within guidelines set in place by the college
- Entering and verifying scores on the college Ellucian software program
- Setup computers for entrance exams (Accuplacer) for future students wishing to enroll
- Greeted students and faculty and answered questions regarding testing concerns and/or complaints
- (part-time)
Utilization Management/Pre-cert Coordinator
Medlogix
06.2006 - 07.2007
- Responsible for verifying ICD9/CPT codes accuracy related to Precertification requests
- Obtain request for medical services via telephone or email, as presented by the treating provider’s office
- Sending dear dr
- Letters to providers to request medical documentation
- Review information given by providers verbally or in writing to ascertain if any information is missing
- Forward appropriate forms to providers
- Document and diary in Medlogix system
- Enter appropriate care plans into the system for Pre-cert nurse to review
- Respond to telephone inquiries of claims that have been assigned to specific Pre-cert team
Workers’ Compensation Health Services Coordinator-Telephonic Case Management
Medlogix
03.2005 - 06.2006
- Responsible for interpreting and documenting medical office notes, coordinating IME’s, onsite referrals and MRI’s, documenting appointments scheduled and provider contact for requests of information, assisting Case Managers with return to work activities regarding injured workers, contacting insurance adjusters, sending introduction and correspondence letters, contacting attorneys for information, obtaining job descriptions from employers, confirm physical therapy compliance, conducting30-day follow-ups and case closures, obtaining medical releases and all other clerical duties as needed
Data Quality/ Credentialing Specialist
Medlogix
07.2003 - 03.2005
- Responsible for creating credentialing files from initial information received from recruiting, coordinating file reviews and approvals by managers as required
- Maintaining documentation and updates, researching, and obtaining verification of physician’s medical experience, professional references, and state licensure, creating, collecting, reviewing and inputting data into computer processing system
- Identifying, sorting, and stamping incoming provider mail
- Updating provider database in Cactus system
- QA output data identify and resolve production related errors maintained and revised procedural lists, verifying information with doctors via telephone or Internet and all other clerical duties as needed
Independent Medical Exam Intake Coordinator
Medlogix
01.2002 - 07.2003
- Responsible for entering all demographics from referrals on clients involved in auto Workers Compensation and liability accidents, assembling clients’ files for claims, ordering all office supplies via Internet, opened and closed file in Excel and contacting insurance adjusters and attorneys for information regarding clients and all other clerical duties as needed
First Report of Injury Representative
Medlogix
12.2001 - 01.2002
- Responsible for answering calls in a call center regarding workers compensation injuries, entering all demographic information regarding the call, contacting insurance adjusters regarding claims and all other clerical duties as needed
Education
Bachelor of Arts - Liberal Studies
Thomas Edison State University
Trenton, NJ12.2024
Business Technology Certificate -
Rowan College At Burlington County
Mount Laurel08.2020
Associate in Liberal Arts And Sciences -
Rowan College At Burlington County
Mount Laurel, NJ04.2020
Skills
- Strong and professional communication skills both written and verbal
- Education management skills
- Over13 years of leadership skills to include training and mentoring
- Expert level decision making skills
- Experience in handling escalation matters within the department
- Strong track record with building rapport with clients and vendors
- Compliant with HIPAA PHI and FERPA laws and regulations
- Over24 years of managed care experience with private, Workers Compensation and Medicaid insurance
Timeline
Operations Quality Auditor
AmeriHealth Caritas
10.2022 - Current
Grievance Appeals Coordinator
AmeriHealth Caritas
08.2021 - 10.2022
Document Processing Specialist
Medlogix
12.2020 - 02.2024
Test Administrator
Mercer County Community College
09.2012 - 03.2012
Team Lead/ Field Case Management Coordinator
Medlogix
07.2007 - 10.2020
Utilization Management/Pre-cert Coordinator
Medlogix
06.2006 - 07.2007
Workers’ Compensation Health Services Coordinator-Telephonic Case Management
Medlogix
03.2005 - 06.2006
Data Quality/ Credentialing Specialist
Medlogix
07.2003 - 03.2005
Independent Medical Exam Intake Coordinator
Medlogix
01.2002 - 07.2003
First Report of Injury Representative
Medlogix
12.2001 - 01.2002
Bachelor of Arts - Liberal Studies
Thomas Edison State University
Business Technology Certificate -
Rowan College At Burlington County
Associate in Liberal Arts And Sciences -
Rowan College At Burlington County
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