Tashyra Young
Milwaukee
Summary
Energetic and compassionate individual with strong analytical skills and keen eye for detail. Well-versed in reviewing medical records and identifying discrepancies within patient care documentation, bringing proficiency in handling complex data and maintaining confidentiality. Dedicated to ensuring accuracy and improving patient care outcomes through meticulous review processes.
Offering solid foundation in analytical thinking and attention to detail, eager to learn and develop within healthcare environment. Delivers strong understanding of medical terminology and healthcare procedures, coupled with proficiency in data management and record-keeping. Ready to use and develop data analysis and review skills in Care Review Processor role.
Developed exceptional analytical and critical thinking skills in healthcare setting, ensuring accurate and efficient review processes. Streamlined documentation and data management procedures, enhancing overall efficiency and accuracy. Seeking to transition into new field, leveraging strong analytical and organizational skills for impactful contributions.
Overview
18
18
years of professional experience
Work History
Care Review Processor
Molina Healthcare
Remote
12.2024 - Current
- Assisted in processing care reviews, ensuring compliance with regulatory standards.
- Supported team by organizing documentation and maintaining accurate records.
- Learned to utilize care management software for efficient data entry and retrieval.
- Collaborated with healthcare professionals to gather necessary information for reviews.
- Contributed to team meetings by providing insights on workflow improvements.
- Adapted quickly to new processes, enhancing overall efficiency of care review operations.
- Participated in training sessions to develop knowledge of policies and procedures.
- Engaged in quality assurance activities to ensure accuracy of processed reviews.
- Contacted physician offices to obtain missing information from authorization requests as requested by medical director.
- Increased efficiency in responding to provider inquiries about case status updates or clarifications needed in submitted documents through effective communication techniques.
Grievance Appeals Specialist
Molina Healthcare
05.2023 - 12.2024
- Resolved escalated cases promptly and effectively, demonstrating strong negotiation skills when liaising with stakeholders.
- Leveraged advanced analytical abilities when evaluating evidence presented in appeal cases, rendering unbiased judgments aligned with organizational policies.
- Optimized workflows within the department by identifying inefficiencies and making recommendations for improvement based on data-driven analysis.
- Contributed to higher client retention rates through exceptional service delivery during the grievance appeals process.
- Reduced case backlog significantly through diligent review and resolution of pending grievances.
- Maintained compliance with regulatory requirements by staying current on industry standards and guidelines.
- Organized regular meetings for the Grievance Appeals team to discuss updates, share knowledge, and address challenges collectively.
- Conducted thorough investigations for complex cases, ensuring fair and accurate outcomes.
- Demonstrated exceptional problem-solving skills when faced with unique or challenging cases, resulting in successful resolutions that satisfied all parties involved.
- Verified client information by analyzing existing evidence on file.
- Posted payments to accounts and maintained records.
Appeals And Complaints Specialist
Skygen Usa
03.2019 - 05.2023
- Analyze, research, and process appeal requests from members and providers regarding denied request for clinical services or payment.
- Communicated effectively with clients, members and providers in the investigation and resolution of various appeals complaints and grievances.
- Documented all appeal, complaint and grievances activity for reporting and trending analysis.
- Created formal correspondences to confirm receipt and provide resolution for members and providers complaints and appeal request.
- Analyzed and process all inbound mail and emails for intake purposes.
- Conducted quality control reviews on complaint data and addressed results with colleagues to influence positive change.
- Maintained strict compliance and regulatory stands for appeals and grievances turnaround times and documentation requirements.
- Maintained a accuracy of 99 percent on resolved cases from start to finish.
- Trained new personnel regarding department operations, policies and services.
- Process Medicare, Medicaid , DSNP and Cotiviti appeals and grievances within timely guidelines allotted by provider.
Customer Support, Billing Support Remote
Skygen Usa
03.2018 - 03.2019
- Continual inbound/outbound call support for medical dental and vision clients including Medicaid, Medicare, Commercial and Dental insurance for providers and members.
- Answered customer telephone calls promptly to avoid on-hold wait times.
- Consulted with outside parties to resolve discrepancies and create expert solutions.
- Researched and resolved billing discrepancies to enable accurate billing.
- Assisted with billing inquiries and provided timely responses to enhance customer satisfaction.
- Provided excellent customer service, developing and maintaining client relationships.
- Monitored customer accounts to identify and rectify billing issues.
- Identified, researched, and resolved billing variances to maintain system accuracy and currency.
- Identified payment trends and adjusted billing processes accordingly to retain customers.
- Maintained strict call center guidelines including call quality, after call work, follow up time.
- Processed check traces, reissued check payments.
Seasonal Customer Consultant
WeEnergies
03.2017 - 10.2017
- Open transfer and close customer residential accounts Refer customers to appropriate programs that exhibit hardship assisted customers with affordable payment agreements.
- Provided exceptional customer service to high-volume customer base, resolving issues, answering inquiries and providing product information.
- Handled difficult customer situations with grace and professionalism, consistently meeting first-call resolution metrics.
- Assisted customers with product selection and troubleshooting, providing accurate information and guidance to foster satisfaction.
- Analyzed customer feedback and generated reports to identify trends and opportunities for improvement.
- Exhibited high energy and professionalism when dealing with clients and staff.
- Sought ways to improve processes and services provided.
- Educated customers about billing, payment processing and support policies and procedures.
- Mediate between customer and third parties services to arrange reconnection or disconnection of utilities.
Loan and Surrender Claims Analyst
Northwestern Mutual
01.2016 - 12.2016
- Viewed reports regularly to make sure processing was conducted efficiently.
- Maintained strict confidentiality with all personal data as per company guidelines.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
- Examined claims forms and other records to determine insurance coverage.
Fraud Claims Support
Fis
09.2014 - 12.2015
- Worked productively in fast-moving work environment to process large volumes of claims.
- Analyzed and addressed escalated claims to resolve issues quickly.
- Followed up with customers on unresolved issues.
- Researched and analyzed complex claims to determine next steps and possible outcomes.
- Updated claims system to track claim status and provide relevant information to other department.
- Prepared and presented detailed reports to management on claims issues to aid in decision making.
- Carried out administrative tasks by communicating with clients, distributing mail, and scanning documents.
- Monitored real-time fraud ques that are populated due to fraud trend systems.
- Evaluated spending trends of customer in accordance with fraud trends to determine if fraud was viable.
- Disputed fraud claims within client regulations.
Early Mid and Late-Stage Collector
Kohl's Corporation
10.2011 - 09.2014
- Delivered exceptional customer service on collection calls and maintained calm and professional demeanor.
- Contacted customers to discuss payment schedules and set up or immediately process payments.
- Persistently reached out to customers with extremely past due accounts to recover lost revenue.
- Achieved performance goals on consistent basis.
- Trained new collections representatives on collections processes and incentivized team members to achieve production goals.
- Reached out to approximately 100-150 account holders daily.
- Documented changes in accounts and on credit reports.
- Negotiated to collect balance in full.
- Used skip tracing and other techniques to locate debtors.
- Registered information of customers on database, collecting credit history, financial statements and personal details to preserve accurate records.
Underwriter/Credit Analyst
Chase Home Finance
03.2008 - 09.2011
- Approve and Deny mortgage loans due to mortgage standards and investor guidelines, Analyze current offers of purchase to determine if they are acceptable by investor, Working with financial documents, tax returns income profit and loss statements, credit reports.
- Analyzing preliminary HUDs, title reports, purchase contracts, appraisals reports and credit reports, Key.
- Contact source for real estate agents and attorneys, Ordering of Brokers Price Opinions, Appraisals (interior and exterior) credit reports and Title Reports, Meet.
- Repayment Plan, Support mortgage lenders in continuously gathering information for loan applicants.
- Key contact for customer during application and process, Set up of mortgage files in regards to all investors including.
- FHA, Conventional, USDA, VA, Continuous documentation of file.
Education
Some College (No Degree) - Human Services Psychology
Walden University
Skills
- Healthcare regulations
- Compliance monitoring
- Assertiveness
- Policy interpretation
- Research
- Collaboration
- HIPAA compliance
- Progress monitoring
- Discharge planning
- Training and education
Timeline
Care Review Processor
Molina Healthcare
12.2024 - Current
Grievance Appeals Specialist
Molina Healthcare
05.2023 - 12.2024
Appeals And Complaints Specialist
Skygen Usa
03.2019 - 05.2023
Customer Support, Billing Support Remote
Skygen Usa
03.2018 - 03.2019
Seasonal Customer Consultant
WeEnergies
03.2017 - 10.2017
Loan and Surrender Claims Analyst
Northwestern Mutual
01.2016 - 12.2016
Fraud Claims Support
Fis
09.2014 - 12.2015
Early Mid and Late-Stage Collector
Kohl's Corporation
10.2011 - 09.2014
Underwriter/Credit Analyst
Chase Home Finance
03.2008 - 09.2011
Some College (No Degree) - Human Services Psychology
Walden University