Tanika Thompson
Milwaukee,WI
Summary
Dedicated Quality Assurance Auditor with 3 years of experience. My goal is to obtain a challenging position in an exciting and motivating environment where I can utilize my skills and knowledge.
Overview
13
13
years of professional experience
Work History
MIRR Appeals and Grievance Coordinator
Molina Healthcare
07.2015 - Current
- Research and provide resolution for member grievances and appeals in a through, professional, and expedited manner
- Research and provide resolutions to member access/availability complaints
- Coordinate workflows between departments and interface with internal and external resources
- Research and resolve complex complaints related to claim processing and member eligibility
- Maintain well-organized, accurate and complete files for all Member Grievances and Appeals
- Provide research and resolution on escalated/urgent cases that are brought forth to the health plan by the Office Commissioner of Insurance and the Better Business Bureau
- Partner with Corporate partners to ensure that root cause of complaints is identified
- Ensure that my completed case files are distributed to the Grievance Panel attendees for review and presentation
- Collaborate with other departments in order to foster an integrated research and resolution approach.
Care Review Processor (Lead)
Molina Healthcare
08.2014 - 07.2015
- Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes
- Verify member eligibility and benefits
- Determine provider contracting status and appropriateness
- Verify inpatient hospital census-admits and discharges
- Notify Care Access and Monitoring Nurses and case managers of hospital admission and charges in member status
- Reporting for management (Medicare & Medicaid) to identify was to improve the current authorization process
- Handled escalated calls on behalf of management
- Assist with formal training needs of new employees.
Care Review Processor 1
Molina Healthcare
04.2013 - 08.2014
- Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes
- Determine diagnosis and treatment request
- Determine Coordination of Benefit status
- Determine provider contracting status and appropriateness
- Contact physician offices to obtain missing information from authorization request or for additional information requested by the CAM Nurses
- Verify member eligibility and benefits
- Responded to incoming calls from providers and internal customer service representatives.
Member Service Rep 2
Molina Healthcare
07.2011 - 04.2013
- Responded to telephone inquiries from both member and providers and provided accurate, efficient and courteous service
- Achieved my individual performance goals that relate to call center objectives
- Assist upper management with various projects as delegated
- Advised members of HEDIS services needed and assisted with scheduling necessary appointments
- Engaged and collaborated with other departments when needed
- Attended training sessions as needed
- Educate Providers on the policies and procedures of the company.
Education
Associate Degree-Medical Assistant -
Bryant & Stratton College
Milwaukee, WI12.2008
Skills
- Extensive knowledge of Marketplace, Medicare and Medicaid Lines of Business
- Medical authorization experience
- Good organizational, time management, customer service and problem-solving skills
- Excellent Verbal and Written Communication skills
- Able to jump in, evaluate, and complete complex and challenging caseloads quickly and effectively
- Ability to exercise flexibility, good judgment and discretion
- Ability to take on additional tasks as needed without letting it hinder my daily responsibilities
References
Available Upon Request
Timeline
MIRR Appeals and Grievance Coordinator
Molina Healthcare
07.2015 - Current
Care Review Processor (Lead)
Molina Healthcare
08.2014 - 07.2015
Care Review Processor 1
Molina Healthcare
04.2013 - 08.2014
Member Service Rep 2
Molina Healthcare
07.2011 - 04.2013
Associate Degree-Medical Assistant -
Bryant & Stratton College
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