Tanesha Orange
Blue Cross NC
Jacksonville,FL
1
Certification
14
years of professional experience
Dynamic Senior-level Escalations and Appeals Specialist with over a decade of expertise in health plan environments, adept at navigating complex, high-risk medical escalations, grievances, and claims determinations. Mastery in end-to-end escalation ownership, advanced investigative techniques, and regulatory compliance within CMS, NCQA, and ERISA frameworks. Recognized for effectively managing high-visibility and sensitive cases involving members, providers, leadership, and regulatory bodies while consistently delivering accurate, defensible, and audit-ready outcomes. Committed to enhancing operational efficiency and ensuring the highest standards of service quality in challenging situations.
Work History
Appeals Analyst | Escalations & Medicare Appeals
2 Years 10 Months- Managed high-risk appeals and grievances, facilitating resolutions for escalated executive-level cases while upholding organizational standards.
- Maintained weekly caseload exceeding 40 cases with 96% accuracy in quality assessments and 98.3% compliance with CMS turnaround timelines.
- Analyzed claims adjudication processes, including eligibility criteria, benefit interpretation, and policy adherence.
- Conducted detailed reviews of ICD/CPT coding and health plan policies to identify discrepancies and compliance issues.
- Authored executive case summaries and position statements aligned with external review requirements.
- Collaborated with medical directors, compliance, legal, and operations teams to resolve escalations and streamline processes.
- Identified trends and systemic issues through data analysis to support operational improvements.
- Ensured adherence to CMS, NCQA, and state regulatory standards.
- Monitored turnaround time SLAs and reporting metrics to maintain regulatory compliance.
- Demonstrated independent judgment in managing complex, high-risk, and ambiguous cases.
- Resolved disputes and enhanced claims processes through cross-functional collaboration.
Complaint & Appeal Liaison | Medicare (Part C)
4 Years 7 Months- Managed high-volume, high-visibility escalations, including leadership-referred and regulatory cases.
- Investigated and resolved claims eligibility and benefit issues through comprehensive end-to-end analysis.
- Identified root causes and trends to drive process improvements.
- Provided guidance on Medicare grievance best practices and ensured compliance with federal regulations.
- Collaborated with legal, compliance, clinical, and operations teams to strengthen processes and support compliance initiatives.
- Prepared executive-level correspondence and case summaries to support strategic decision-making.
- Strengthened stakeholder communication channels to improve alignment and operational efficiency.
- Developed and delivered training materials to enhance staff understanding of organizational processes and compliance standards.
Triage Coordinator | Medicare Part D
2 Years 7 Months- Reviewed incoming appeals to determine priority and route cases to appropriate departments.
- Analyzed coverage determination trends to improve workflow efficiency and support informed decision-making.
- Maintained accurate documentation to ensure compliance with CMS requirements.
- Coordinated patient triage processes, ensuring timely and accurate assessment of healthcare needs.
- Collaborated with multidisciplinary teams to support seamless patient care transitions and continuity of care.
Appeals Analyst | Medicare Part D
1 Year 7 Months- Evaluated and resolved complex pharmacy appeals while ensuring strict compliance with CMS guidelines.
- Identified trends within appeals data to enhance process efficiency and streamline operations.
- Collaborated with cross-functional teams to strengthen claims resolution strategies and improve outcomes.
Member Services Representative | Medicare
2 Years- Communicated with members regarding claims and coverage inquiries, escalating complex issues to appropriate departments as needed.
- Managed member interactions by providing timely, effective issue resolution to enhance service quality.
- Developed and delivered educational materials on benefits, eligibility, and claims processes to improve member understanding and engagement.
Education
- Medical Billing & Coding
- National Certified Insurance & Coding Specialist (NCICS)
Skills
Escalation Management
Case Resolution
Advanced Investigation
Root Cause Analysis
Claims Adjudication
Regulatory Compliance (CMS
ERISA
NCQA)
Executive Communication
Cross-Functional Collaboration
Audit Readiness
Trend Analysis
Process Improvement
Microsoft Excel
PowerPoint
Case evaluation
Verbal communication
Policy interpretation
Certification
Project Management Certification – In Progress
Timeline
Appeals Analyst | Escalations & Medicare Appeals
Blue Cross NC
08.2023 - CurrentRead More
Complaint & Appeal Liaison | Medicare (Part C)
Aetna (CVS Health)
01.2019 - 08.2023Read More
Triage Coordinator | Medicare Part D
Aetna (CVS Health)
05.2016 - 12.2018Read More
Appeals Analyst | Medicare Part D
Aetna (CVS Health)
10.2014 - 05.2016Read More
Member Services Representative | Medicare
Aetna (CVS Health)
10.2012 - 10.2014Read More
from National Certified Insurance & Coding Specialist (NCICS)
Read More
Florida Technical College
from Medical Billing & Coding
Read More