Ternecia Fesser
Wimauma,FL
Summary
To obtain a meaningful and challenging position that would enable me to utilize my analytical and technical skills to improve the company’s profitability.
Overview
15
15
years of professional experience
Work History
Member Services Claims Remote
WellDyneRx
09.2022 - Current
- Xcelys Production Processing,
- Processed 80-150 claims per day depending on medical queues
- Medicare and Medicaid Processing regulations
- Prepare files for loading onto claims platform (Xcelys)
- Pull/ Load professional contracts into Xcelys through appropriate research and provider data load activities
- Track project plan and gather updates concerning provider data from team leads as needed
- Build pricing packages
- Load provider files and audit completion
- Update changes in member's benefit enrollment
- Reinstatement of a member's benefit enrollment
- Disenrollment of members (i.e., termination of plan membership)
- Build rules within Paradigm System, in coordination within State and Federal guidelines
- Monitor and test accuracy of price rules
- Reviewing and researching insurance claims to determine possible payment accuracy
- Validating Member, Provider and other Claims information
- Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
- Recommended specific products and services in alignment with individual needs, requirements and specifications.
- Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences.
- Investigated and resolved customer inquiries and complaints quickly.
- Educated customers about billing, payment processing and support policies and procedures.
Donor Service Specialist-Team Leader
OneBlood
10.2016 - 10.2021
- Collect blood and tissue samples with focus on accuracy and adherence to aseptic techniques.
- Specialized in conducting tests with accuracy and precision.
- Kept supplies organized and well-stocked, requesting more supplies and avoiding unnecessary testing delays.
- Identified and traced quality control issues impacting laboratory results.
- Documented and verified patient information using laboratory information system.
- Maintained safe work environment free of unnecessary hazards to protect staff and testing results.
- Analyzed and interpreted data, accurately identifying and reporting laboratory results.
- Troubleshot problems with equipment and recalibrated devices or brought serious concerns to supervisor for handling.
- Reviewed insurance and claims documents to verify required information and secure any missing data for settlements.
- Provided advice to customers regarding claims, rights and insurance processes to prevent disputes.
Executive Administrative Assistant
Tampa Tax Service
09.2008 - 04.2018
- Determining customer service issues of members and providers and resolving the issue
- Assisting team members with difficult customer service calls and identify targeted training areas
- Coordinate training/coaching opportunities for all new team members and provide leadership and support to assist them in reaching there desired goals
- Managing department monitoring procedures of established performance standards
- Assist callers in understanding the nature of LifeSynch Services
- Handled scheduling for executive's calendar and prepared meeting agenda and materials.
- Responded to emails and other correspondence to facilitate communication and enhance business processes.
- Produced accurate office files, updated spreadsheets, and crafted presentations to support executives and boost team productivity.
Prior Authorization Specialist
Health Plan Services
11.2016 - 09.2017
- Provider contract loading and using various databases and/or source documents
- Research Installation Issues and develop customer specific resolution
- Audit contract, benefit and/or pricing configuration for adherence to quality measures and reporting standards
- Overall Health Plan benefit loading and using various databases and/or source documents
- Research Benefit Issues and develop configuration to provide customer resolution
- Set priorities on daily operational activities such as completing team track tasks
- Ensure quality and quantity produced by operational teams
- Ensure executions meeting predefined Service Level Agreements
- Reviews, interprets and loads provider fee schedules and contracts into various claims payment system platforms, such as FACETS and/or DIAMOND, to support UHC Community & State business
- Serve as subject matter expert on pricing and configuration methodologies
- Identify and resolve operational issues using defined processes and methodologies
- Follow appropriate protocol for utilizing performance tools such as Omega, DAA, and IEX
- Review proposed defects or causes of rework that have been attributed to the Benefit Configuration Operations (BCO) team
- Reference procedures, sources of truth (policies, benefit matrices, etc.), and Facets configuration history to be able to respond
- Review daily pended error claim report to identify and resolve the issues in order to meet states’ Performance Guarantees.
- Input all patient data regarding claims and prior authorizations into system accurately.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Researched claims and incident information to deliver solutions and resolve problems.
Customer Service Representative
General Dynamics
10.2015 - 11.2016
- Processed claim forms, adjudicates for provision of provision of deductibles, copays, coinsurance maximums and provider settlement
- Entered claims data into system
- Process Medicare, Medicaid Physician and Hospital claims
- Analyze provider contracts also update provider tax id numbers and address
- Handled customer inquiries and suggestions courteously and professionally.
- Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.
- Answered constant flow of customer calls with minimal wait times.
- Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
Education
Associate of Applied Science - Health Administration
Hillsborough Community College
Tampa, FL12.2026
High School Diploma -
Cornerstone Christian Correspondence School
Townsend, GA05.2009
Skills
- Medicaid/Medicare/
- Commerical Healthcare/PPO/HMO/POS
- Claims Payment & Adjustment
- Insurance Billing & Coding
- Customer Service
- Quality Assurance & Audits
- Change Management
- Project Management
- Benefit and Provider Configuration
- User Acceptance Testing
- Train/Mentor
- PeopleSoft
- Sharepoint
- Outlook
- Word
- Excel
- PowerPoint
- Access
- SQL
- SnowFlake
- NDB
- Facets
- Business Objects
- Team Track
- Navigator
- Pricing & Cost Analysis
- Report Preparation
- Contract Analysis
Timeline
Member Services Claims Remote
WellDyneRx
09.2022 - Current
Prior Authorization Specialist
Health Plan Services
11.2016 - 09.2017
Donor Service Specialist-Team Leader
OneBlood
10.2016 - 10.2021
Customer Service Representative
General Dynamics
10.2015 - 11.2016
Executive Administrative Assistant
Tampa Tax Service
09.2008 - 04.2018
Associate of Applied Science - Health Administration
Hillsborough Community College
High School Diploma -
Cornerstone Christian Correspondence School
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