Tanisha Montgomery
Bolingbrook,IL
Summary
Analytical health care coordinator with expertise in case management and regulatory compliance. Experienced in evaluating grievances and appeals, preparing detailed response letters, and collaborating effectively with stakeholders to uphold high standards of service and compliance.
Overview
12
12
years of professional experience
Work History
Grievance and Appeals Coordinator I
Centene Corporation
Burr Ridge, IL
04.2022 - Current
- Management of large volumes of documents received via interdepartmental communication, U.S. mail, email, and fax transmission.
- Determining whether cases have merit based on the facts of the case and applicable law and recommending whether cases should be accepted or rejected.
- Prepare response letters for member and provider complaints, grievances, and appeals.
- Assist with HEDIS production functions, including data entry, provider office calls, and claims research.
- Retrieve assigned cases from the queue and review for the proper route of documents or correspondence.
- Effective communication (written and verbal) documenting all communications with members, providers, nursing staff, medical directors, and Appeal Supervisors.
- Consistently applying internal administrative and state criteria when validating the accuracy of incoming grievances and appeals.
- Daily collaboration with the department manager and supervisors on identifying any internal or external issues related to document intake, appeal and grievance processes, and database support.
Utilization Case Manager
SeniorWell
Buffalo Grove, IL
04.2017 - 06.2020
- Obtain recommendations from doctors and enter in the appropriate computer systems.
- Determine proper payer source.
- Check Medicaid website for eligibility for appropriate prosthetic or send signed medical clearance to Medicaid for prior authorization.
- If suspended or denied, address it with Medicaid or Liability program.
- Upon receipt of payment for private payer or verification from Medicaid, patient is eligible; send recommendation to lab and doctor.
- Give all necessary paperwork to the biller.
Customer Service Call Center
Byram Healthcare
Downers Grove, IL
08.2016 - 04.2017
- Answered, screened and processed high volume of calls daily with call management system and web-based communications.
- Receive and process customer orders.
- Properly directed inbound calls in phone queues to improve call flow.
- Assessed customer needs and up-sold products and services to maximize sales.
- Maintain confidentiality of company associates and patient information.
Customer Service Consultant
Prism Healthcare Service Inc.
Schaumburg, IL
11.2014 - 08.2016
- Maintained up-to-date knowledge of Medicare, Medicaid, and insurance policy guidelines to provide accurate information and support to patients and staff.
- Answered incoming patient and referral calls, verifying all information using appropriate forms to ensure accuracy and compliance.
- Monitored departmental activities to identify areas for operational improvement and enhance service delivery.
- Support sales team in maintaining good relationships with key accounts.
Skills
- Regulatory compliance
- Insurance plan verification
- Case management
- Proficient in Availity, CMS/Medicaid/Carrier websites and EPIC computer systems
- Strong ability to deal with high call volume and complex service issues
- Training program management
- Strong communication and presentation skills
References
- References available upon request
Timeline
Grievance and Appeals Coordinator I
Centene Corporation
04.2022 - Current
Utilization Case Manager
SeniorWell
04.2017 - 06.2020
Customer Service Call Center
Byram Healthcare
08.2016 - 04.2017
Customer Service Consultant
Prism Healthcare Service Inc.
11.2014 - 08.2016