Teonna Wilson
Tyler,TX
Summary
Precise medical case management professional with over ten years of experience. I specialize in filing claims, processing referrals, quality control and implementing processes to enhance the process of business, billing, and medical records departments.
Overview
12
12
years of professional experience
Work History
CHCS Longterm Care, State Farm
02.2023 - 10.2024
- Responsible for accurate/timely daily review of Long-Term Care claims and policy provisions to process payment or issue denial. This role does not involve full claim handling from claim receipt or intake to closure. In terms of claims handling, this position is specifically limited to the payment or adjudication of invoices pertaining to long-term care claims.
- Responsible for the identification, analysis and application of long-term care claim product features including waiver of premium, waiting period, assignment of benefits, credits, and other applicable policy benefits. Meet or exceed the minimum production and quality targets as approved by management.
- Respond accurately, timely and professionally to all oral and written external and/or internal correspondences received from stakeholders regarding benefits, eligibility, claim payments, denials and/or explanation of benefits. As well as inbound claim calls.
- Maintain working knowledge of all company services pertaining to business segment, company claims, administrative and imaging software systems such as INSPRO and Microsoft applications
- Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines.
Quality Analysis
Maximus Health Care
03.2022 - 08.2023
- Monitor, inspect and propose measures to correct or improve a company’s final products and processes to meet established quality standards.
- Prepare and implement quality assurance policies and procedures. Perform routine inspections and quality tests.
- Identify and resolve workflow production issues to ensure that standards and safety regulations at the company are observed.
- Discuss issues and proposed solutions with superiors and document activities creating audit reports.
- Enforce guidelines and procedures for collecting and oversee implementation to ensure inspection efficiency.
- Analyze customer grievances and other non-compliance issues and make their recommendations based on their findings.
Health Concierge
Aetna/CVS Pharmacy
03.2021 - 01.2023
- Educates and assists customers with various elements of benefit planning information and available services created to enhance the overall customer service experience with the company.
- Handle customer service inquiries and problems via telephone, internet, webchat or written correspondence.
- Provide claim status information, benefit coverage interpretations and explaining plan eligibility.
- Schedule and coordinate appointments for hospital providers, private practices, specialists.
- Collect payments, update patient data, develop payment plans, and prepare invoices.
Medical Case Investigator
TEK Systems
05.2020 - 03.2021
- Obtained and reviewed patient demographic, location, laboratory, clinical, and risk information available in health department surveillance systems or other data systems to determine investigation priorities.
- Initiated prompt communication with patients diagnosed with COVID-19 through text, phone calls, email, and other communication platforms.
- Reviewed clinically documented and patient's self-reported COVID19 symptom history to determine the timeframe when the patient was infectious.
Patient Access Rep
Christus Mother Frances
02.2016 - 02.2021
- Submits insurance claims to third party payors electronically and on paper. Follows up on unpaid third-party claims to resolution (payment or denial).
- Evaluations and processes account for adjustments, charity, outside assistance or bad debt. Analyzes accounts to ensure full reimbursement and to satisfy patient and/or insurance company inquiries.
- Collects balances due from patients using phone calls, personal contact, statements, letters or third-party services.
- Receives, processes and responds to correspondence or phone inquiries from patients, guarantors, insurance companies, attorneys, etc.
- Compiles data, tracks results and reports to management.
- May be assigned specialty responsibilities in the areas of refunds, reconciliation, balancing and/or posting and in data collection and analysis.
- Handles difficult patient account management issues referred to by other staff.
- Assists managers with various duties including, but not limited to, review of write-offs, adjustments, refunds and discounts; coordinating work group activities; and training of other staff.
Referral Specialist
United Way of Smith County
09.2012 - 03.2016
- Accurately assesses clients’ needs and provides thorough, appropriate, and helpful referrals to address those needs; uses direct intervention and advocacy when needed and agreed to by the client; processes applications for direct financial assistance within specified guidelines.
- Maintain current information on available community resources and ensure that other resources are aware of the function of United Way’s 211 to maximize the effectiveness of the program in meeting client needs.
Education
Diploma - undefined
John Tyler High
01.1992
Billing/Coding Certification - undefined
University of Phoenix
01.2021
Skills
- Expert in most EMR systems (AS400, EPIC, HER, GROUP WISE, ECW)
- Dependable
- Excellent problem solving
- Patient confidentiality
Timeline
CHCS Longterm Care, State Farm
02.2023 - 10.2024
Quality Analysis
Maximus Health Care
03.2022 - 08.2023
Health Concierge
Aetna/CVS Pharmacy
03.2021 - 01.2023
Medical Case Investigator
TEK Systems
05.2020 - 03.2021
Patient Access Rep
Christus Mother Frances
02.2016 - 02.2021
Referral Specialist
United Way of Smith County
09.2012 - 03.2016
Diploma - undefined
John Tyler High
Billing/Coding Certification - undefined
University of Phoenix