Summary
Overview
Work History
Education
Skills
References
Timeline
Generic
Tanya Lemons

Tanya Lemons

Sacramento,CA

Summary

Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.

Overview

27
27
years of professional experience

Work History

Authorization Specialist II

Health Net
11.2024 - Current
  • Monitors authorization requests for services according to insurance requirements and routes to clinical reviewer.
  • Verifies and assesses member insurance coverage and/or service/benefit eligibility via system tools and aligns authorization with the guidelines to ensure a timely adjudication for payment
  • Performs data entry to maintain and update some complex authorization requests into utilization management system
  • Maintains ongoing tracking and appropriate documentation on authorizations and referrals in accordance with policies and guidelines
  • Develops in-depth knowledge of prior authorization review process and insurance coverage to support prior authorization process for clinical reviewers and providers
  • Research health plan providers and polices to identify preferred in-network providers and requirements for referral authorization; provides supporting documentation to health plan
  • Provides some guidance and support of the authorization review process by researching and documenting necessary medical information such as history, diagnosis, and prognosis based on the referral to the clinical reviewer for determination
  • Maintains relationships with service providers and clinical reviewers to ensure referrals are addressed in a timely manner
  • Act as a subject matter expert to other team members for the overall authorization process and for multiple service types at different levels of urgency
  • Remains up to date on healthcare, authorization processes, policies and procedures
  • Strong knowledge of medical terminology and insurance
  • Performs other duties as assigned
  • Complies with all policies and standards

Grievance and Appeals Specalist

Delta Dental
06.2022 - Current
  • Researches and responds directly to members, providers, clients, internal departments and regulatory bodies
  • Prepares formal responses with the assistance of the legal department
  • Supports the legal department with small claims court appearances
  • Researches and responds to HIPAA inquiries and complaints.Provides materials and sends inquiries regarding NPP
  • Prepares formal responses to subscriber privacy concerns
  • Reports complaint trends to legal counsel and management as determined by analysis of the complaint tracking system
  • Performs miscellaneous duties as assigned.

Data Support SpecialistSupport

Health Net
01.2016 - 06.2022
  • Specialist will assist the sales staff with data entry
  • Liaison between the state and internal clients
  • Reviews all incoming mail for project request verification
  • Reviews all incoming mail for priority status justification
  • Creates detailed spreadsheets which include, but are not limited to, member plan line of business, ervice center, member name, member identification, provider information, etc Updates spreadsheets when projects are completed with the appropriate closure information
  • Enters and maintains project information with the current (Access and/or SQL) research database
  • Maintains project files.Assesses and routes project issues appropriately and timely.Files documents

Cash/Accounts Receivable Specialist

Health Net
01.2011 - 01.2016
  • Scans, tracks, and maintains detailed logs of all checks received from providers and third party recovery vendors for all Health Net entities so that proper determination of the claims associated with the checks can be completed
  • Coordinates with the claims adjustment team via telephone, Service Forms (SF) or other means of communication to ensure timely resolution of all cash received
  • Processes accounts receivable and applies all cash receipts to claims in the appropriate claims and/or financial systems in accordance with pre-established turn around times after the research is completed by the claims adjustment team
  • Processes complex and detailed cash application scenarios requiring the associate to make processing decisions fro available options that impact the
  • General Ledger
  • Provides professional customer service to participating providers, out of area providers, and/or subscribers to resolve problems or questions in payment
  • Must be able to clearly communicate how cash receipts were used to satisfy the provider receivable accounts
  • Communicates with bank institutions concerning stop payments, cleared check questions, forgeries
  • Prepares daily Access Database reports that document the posting and balancing of all cash activity and correspond to the claims and financial systems
  • Refunds money paid to Health Net in error through completion of manual check requests to be sent to
  • Corporate Accounts Payable
  • Logs and tracks these requests to ensure refund is completed and balanced
  • Provides a response to all Service Forms (SF's) within established departmental policy to maintain provider satisfaction
  • Assists in Special Department in
  • Recovery and claims department and other assignments as directed.

Customer Services Rep

Health Net
03.2008 - 01.2011
  • I
  • Handles general inbound ACD calls, correspondence, and lobby visits related to all aspects of service
  • Effectively communicates, written and verbally, Health Net policies, procedures, and applicable benefits to members and/or providers who have misinterpreted, were unaware of, or are questioning a Health Net policy or decision
  • Researches claims according to established policies and procedures
  • Determines claim status and consults with appropriate staff and/or management on all questionable claims in order to ensure proper disposition
  • Must meet departmental standards for quality, productivity and teamwork
  • Communicates accurate information to customer questions and requests, by phone and/or in writing, in a courteous and professional manner
  • Able to handle difficult and sensitive issues appropriately; maintains highest level of customer confidentiality
  • Investigates customers’ problems as indicated
  • Initiates appropriate action to ensure timely resolution
  • Interacts with staff in other departments to clarify problems presented by customers and to obtain accurate information
  • Develops and maintains a comprehensive knowledge of all
  • Health Net policies, procedures, products and services including departmental processes of
  • Medical Management, Network Management, Sales & Marketing and Government Programs
  • Identifies, analyzes and performs any of the following
  • Member/Provider eligibility and benefit questions and research and interpretation of claims, including all aspects of COB, NF, ICD 9 codes
  • Worker’s compensation and claim recovery All correspondence including internet correspondence, emergency room appeals, member and employer questionnaires, enrollment applications and Authorization Services forms
  • Referrals/Authorizations research Facilitates filing of appeals and grievances Plans (including all Non-Standard Plans, ASO, and Government
  • Programs) Enrollment and Eligibility Benefit Product comparisons, Exclusions, Limitations, and Product nuances Interpret Health Net remittance advices and member EOB’s
  • Performs data input in a highly accurate and timely fashion for all customer contacts according to the customer information database system parameters
  • Assures documentation is complete, so department is able to monitor physician compliance
  • Participates in various training and information functions available to the
  • Health Plan Operations staff members to enhance skills, improve performance, and contribute to the ongoing development and achievement of departmental goals
  • Has an understanding of, and is able to communicate member benefits, reimbursement policies, coding guidelines, the appeal and grievance procedures, and company policy to all customers.

Enrollment Consultant

Aetna Healthcare Inc
01.1998 - 03.2008
  • Responds, researches, and resolves eligibility and/or billing related issues involving member specific information; Works directly with clients, field marketing offices and/or local claim operations to achieve positive service outcomes
  • Monitors daily status reports assessing output for developing trends potentially impacting service levels
  • Applies all appropriate considerations associated with technical requirements, legislative/regulatory policies, account structure and benefit parameters in addressing eligibility matters
  • Validates benefit plan enrollment information for assigned clients for accuracy and completeness; Enroll in Cobra, Conversion plans coordinates the distribution of membership
  • ID cards and partnering with appropriate internal/external support areas involving any requests for ID card customization
  • Completes screen coding and data entry requirements related to the systems processes impacting the generation and release of member-specific and plan sponsor products (e.g., ID cards, change applications, audit lists, in-force lists, HIPAA certificates and various reports)
  • Completes data entry requirements for finalizing new enrollment information as well as for changes and/or terminations
  • When necessary, reviews and corrects transaction errors impacting eligibility interfaces and prepares eligibility/enrollment information for imaging
  • Interprets and translates client benefits and supporting account structure against internal systems/applications
  • Determines and communicates standard service charges to internal/external customers related to paper eligibility activities; May include negotiating and communicating charges pertaining to non-standard services
  • Partners with other team functions to coordinate the release of eligibility and benefit plan information; reproduces group bills if requested by clients.

Education

Associates Degree - Business Administration

Phillips Junior College
01.1991

General Studies

Other Roosevelt High School
01.1988

Skills

  • Windows XP, Rent Roll, MS Office packages Word, Access, Excel and PowerPoint, Outlook and
  • HudManager
  • WordPerfect 60
  • Verbal and Written Communication
  • Payment and Investigation Escalations
  • Organizing and Prioritizing Work
  • Time Management
  • Policy and Procedure Explanations
  • Decision Making
  • Attention to Detail
  • Regulatory Compliance Adherence

References

References Upon Request

Timeline

Authorization Specialist II

Health Net
11.2024 - Current

Grievance and Appeals Specalist

Delta Dental
06.2022 - Current

Data Support SpecialistSupport

Health Net
01.2016 - 06.2022

Cash/Accounts Receivable Specialist

Health Net
01.2011 - 01.2016

Customer Services Rep

Health Net
03.2008 - 01.2011

Enrollment Consultant

Aetna Healthcare Inc
01.1998 - 03.2008

Associates Degree - Business Administration

Phillips Junior College

General Studies

Other Roosevelt High School

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