Tenesha Phillips
New Caney,TX
Summary
Detail-oriented Healthcare Claims and Data Quality Professional with 8+ years of experience in reviewing and processing claims for accuracy and compliance. Expertise includes handling Medicare-rejected and high-dollar claims, along with data validation and quality auditing. Recently completed a Medical Billing and Coding program and preparing for CPC certification. Seeking remote roles in claims quality, payment integrity, or healthcare data analysis.
Overview
1
1
Certification
19
19
years of professional experience
Work History
Claim Data Specialist
CVS
Houston, TX
10.2018 - Current
- Review and process healthcare provider claims for accuracy, completeness, and compliance with applicable payer and plan guidelines.
- Research Medicare-rejected claims, identify rejection causes, and determine appropriate resolution based on claim data and established guidelines.
- Process and research corrected claims, including complex and high-dollar claims, to support accurate adjudication and payment.
- Review DME claims and supporting information for accuracy, appropriate billing, and reimbursement requirements.
- Conduct claim quality audits to identify discrepancies, coding or billing issues, and opportunities to improve data accuracy and compliance.
- Analyze claim information and system data to identify errors, trends, and potential payment issues; document findings and corrective actions.
- Validate claim data entered into internal systems and resolve discrepancies to maintain accurate and complete records.
- Research claim history, policy requirements, and related documentation to resolve complex claim issues and outstanding discrepancies.
- Communicate with healthcare providers, insurance partners, and internal teams when clarification or additional information is needed.
- Maintain productivity, accuracy, and quality standards while managing high-volume claim research and processing.
Senior Customer Service Representative
AETNA
Houston, TX
04.2013 - 10.2018
- Managed healthcare customer inquiries and escalated issues, ensuring accuracy, professionalism, and confidentiality.
- Resolved escalated calls by evaluating customer needs, gathering relevant information, and presenting suitable solutions.
- Investigated customer and benefit information to diagnose issues and deliver effective resolutions.
- Applied knowledge of internal policies, procedures, and healthcare services to resolve complex inquiries.
- Assisted with training and mentoring new team members on processes, procedures, and service expectations.
- Monitored performance metrics including call volume, wait times, and resolution times while meeting established service standards.
Medical Assistant
Cleveland Pediatric Clinic
Cleveland, TX
01.2009 - 01.2012
- Facilitated patient intake, room preparation, vital signs measurement, documentation, and routine clinical office procedures to ensure efficient workflow.
- Supported physicians in patient care by efficiently taking vital signs and histories, and preparing patients for examinations.
- Administered immunizations and performed basic laboratory tests as needed.
- Upheld accurate patient information and collaborated with providers and families to enhance care quality in a pediatric clinical environment.
Medical Assistant
Calvary Medical Clinic
Cleveland, TX
01.2008 - 01.2009
- Administered injections, medications and treatments as directed by the physician.
- Assisted physicians with patient examinations and medical procedures.
- Assisted healthcare staff with patient care activities while maintaining accurate records and following established procedures.
- Supported clinical and administrative operations, including patient intake, documentation, and routine office procedures.
Education
Medical Billing & Coding Program -
University of Houston
Houston, TX08-2026
Certificate in Clinical Medical Assistant -
Everest Institute
Houston, TX11-2008
High School Diploma -
Goodrich High School
Goodrich, TX05-2002
Skills
- Claims Adjudication
- Claims processing
- Medicare claims
- DME Claims
- Complex claims
- Payment accuracy
- Quality auditing
- Claims analysis
- Data validation
- ICD-10-CM
- CPT
- HCPCS
- Medical Terminology
- Reporting documentation
- Microsoft Office
- Stakeholder Engagement
Personal Information
Title: Healthcare Claims & Data Quality Specialist
Certification
CPC (Certified Professional Coder), Exam Preparation in Progress
Education And Professional Development
- Medical Billing & Coding Program, 08/01/26, Final Grade: 93.3% | CPC Certification Exam Preparation in Progress
- Certificate in Clinical Medical Assisting, Everest Institute, Houston, TX, 11/01/08
- High School Diploma, Goodrich High School, Goodrich, TX, 05/01/02
Timeline
Claim Data Specialist
CVS
10.2018 - Current
Senior Customer Service Representative
AETNA
04.2013 - 10.2018
Medical Assistant
Cleveland Pediatric Clinic
01.2009 - 01.2012
Medical Assistant
Calvary Medical Clinic
01.2008 - 01.2009
Medical Billing & Coding Program -
University of Houston
Certificate in Clinical Medical Assistant -
Everest Institute
High School Diploma -
Goodrich High School