T'CHRISSA BURKS
CHARLESTON,US
Summary
Experienced appeals and grievances coordinator adept at building effective processes and obtaining reliable, accurate information for business decision making.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Grievance Coordinator
Randstad
10.2023 - Current
- Enhanced grievance resolution rates by implementing efficient tracking and monitoring systems.
- Maintained accurate records of all grievance cases, facilitating easier reporting and analysis of trends.
- Identified areas for policy improvement through thorough analysis of recurring grievance themes, leading to proactive problem resolution.
- Conducted comprehensive investigations on complex cases, leading to successful outcomes and satisfied clients.
- Reduced case backlog by prioritizing urgent grievances and effectively delegating tasks to team members.
Appeals Coordinator
Billing Solutions
08.2023 - Current
- Triage and appeal denied claims while researching and investigating payer denials
- Review and process medical necessity, timely filing, and no pre-authorization appeals along with additional denials received while professionally communicating the information to leadership
- Reviewing and processing claim errors and corrections for resubmissions.
Appeals Analyst I
Elevance Health
02.2022 - 07.2023
- Reviewed, analyzed, and processed complex and non-complex grievances and appeals in accordance with external accreditation and regulatory requirements
- Utilized internal policies and claims events requiring adaptation of written response in clear understandable language
- Thoroughly utilized guidelines and reviewed tools to conduct extensive research and analyzed the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff
- Analyzed and rendered determinations on assigned non-clinical grievance and appeal issues and completion of the respective written communication documents to convey the determination while following department guidelines and tools to complete reviews.
CSR 1
Elevance Health
11.2020 - 02.2022
- Responded to customer inquiries via telephone regarding insurance benefits, provider contracts, and eligibility
- Analyzed problems and provided information and solutions
- Operated a PC station to obtain and extract information; documented information and activities and changes in the database
- Thoroughly documented inquiry outcomes for accurate tracking and analysis
- Developed and maintained positive customer relations while coordinating with various functions within the company to ensure customer requests and questions were handled appropriately and in a timely manner
- Researched and analyzed data to address operational challenges and customer service issues
- Received and placed follow-up telephone calls to answer customer questions that are routine in nature while using computerized systems for tracking information gathering and troubleshooting
- Sought to understand and responded to the needs and expectations of customers required to meet and exceed department goals
- Serviced inbound calls from prospects to provide employment screening and job matching services while assisting callers with developing a lead with enrollment with higher education institutions.
Employment and Education Advisor
Liquid Education
10.2018 - 10.2020
- Gathered clinical information regarding the case and determined the appropriate area to refer or assign the case (utilization management, case management, QI, Med Review)
- Provided information regarding network providers or general program information when requested
- Assisted with complex cases while acting as a liaison between Medical Management Operations and internal departments
- Maintained and updates tracking databases and prepared reports.
Medical Management Specialist
Unicare
10.2017 - 09.2018
- Provided initial contact between distinct Quality Management programs and specific identified members
- Under indirect supervision handled inbound/outbound enrollment and engagement calls with eligible members to provide information regarding program features.
Health Program Representative
Aerotek (Unicare)
05.2017 - 08.2017
- Gathered and recorded appropriate member information in accordance with policies and procedures via telephone
- Encouraged members to participate in the Quality Management programs by providing information about the program
- Outlined program features/value and explaining available services
- Recorded call details and utilized call scripts as needed based on client requirements
- Directed member inquiries to appropriate clinical staff
- Gathered information from hospitals, health plans, physicians, patients, vendors, and other referral sources
- Contacted physician offices to obtain demographic information related data as needed
- Sent reports to various state plans and departments
- Identified providers who haven't returned their recredentialing applications or who were past-due for credentialing
- Monitored reports and followed-up on ongoing state license action and Medicare/Medicaid sanctions
- Consistently and appropriately performed all assigned tasks of the credentialing process within the required time frames according to Molina policy and procedures for individual providers and Health Organizations
- Communicated effectively and in a professional manner with external contacts, providers, and all employees of Molina while maintaining a high level of confidentiality for provider information.
Credentialing Specialist Lead
Aerotek (Unicare)
11.2015 - 11.2016
- Managed calls in a personal systematic and organized manner following departmental guidelines and utilizing proper use of terminology
- Routed calls internally using appropriate CSC guidelines while actively listening and probing callers in a professional and timely manner to determine the purpose of the calls
- Researched and articulately communicated information to callers while maintaining confidentiality
- Comprehensively assembled and entered member and provider information into the appropriate system to initiate the requested transportation services
- Performed necessary follow-up tasks to ensure member or providers' needs were completely met
- Assumed full responsibility for self-development and career progression.
CSR II
MTM
10.2014 - 10.2015
- Acquired, adhered to, and maintained in-depth knowledge of CSC Protocols and Procedures and MTM's Transportation Provider Network
- Provided personal instruction, demonstrated appropriate educational activities; and delivered research-based printed materials to parents regarding child development and related issues
- Conducted child developmental screenings including vision, hearing, and the understanding and use of language, motor development, hand-eye coordination, and health and physical development for children birth to age three.
Parent Educator
East End Family Resource Center
06.2011 - 10.2014
- Audited and verified payroll records for investigation of unemployment claims
- Collected and analyzed data to detect duplicated effort, fraud, or noncompliance with laws, regulations, and management policies
- Maintained auditing records and determined the scope of investigation required on a case-by-case basis
- Prepared detailed reports on audit findings.
Interviewer 3
Workforce West Virginia
01.2014 - 08.2014
Education
HIGH SCHOOL DIPLOMA -
CAPITAL HIGH SCHOOL
CHARLESTON, WV01.2006
Skills
- Analyze data
- Appeals Review
- Attention to Detail
- Auditing
- Time Management
- Critical Thinking
- Interpersonal Communications
- Verbal Communication
- Problem Solving
- Dispute Resolution
- Policy Knowledge
- Policy analysis
- Multitasking
- Adaptability and Flexibility
- Effective Communication
- Interpersonal Communication
- Problem-solving abilities
Certification
- Microsoft Office 2019 Certification
- CMS Part C Organization Determinations, Appeals, and Grievances Certification
- CMS Part D Coverage Determinations, Appeals, and Grievances Certification
- CMS World of Medicare Certification
- CMS Combating Medicare Parts C & D Fraud, Waste, & Abuse Certification
- CMS Medicare Fraud & Abuse: Prevent, Detect, Report Certification
Timeline
Grievance Coordinator
Randstad
10.2023 - Current
Appeals Coordinator
Billing Solutions
08.2023 - Current
Appeals Analyst I
Elevance Health
02.2022 - 07.2023
CSR 1
Elevance Health
11.2020 - 02.2022
Employment and Education Advisor
Liquid Education
10.2018 - 10.2020
Medical Management Specialist
Unicare
10.2017 - 09.2018
Health Program Representative
Aerotek (Unicare)
05.2017 - 08.2017
Credentialing Specialist Lead
Aerotek (Unicare)
11.2015 - 11.2016
CSR II
MTM
10.2014 - 10.2015
Interviewer 3
Workforce West Virginia
01.2014 - 08.2014
Parent Educator
East End Family Resource Center
06.2011 - 10.2014
HIGH SCHOOL DIPLOMA -
CAPITAL HIGH SCHOOL
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