Summary
Overview
Work History
Education
Skills
References
Accomplishments
Websites
Certification
Affiliations
Timeline
Generic

Jaiann Caton

United States

Summary

Dynamic healthcare professional with extensive experience at CVS Pharmacy, excelling in credentialing verification and compliance monitoring. Proven ability to enhance operational efficiency, achieving a 30% reduction in claim turnaround time. Skilled in relationship building and problem-solving, with expertise in high-volume medical billing and regulatory compliance.

Overview

9
9
years of professional experience
1
1
Certification

Work History

Care Review Processor

CVS Pharmacy
Alpharetta, GA
05.2024 - Current
  • Verified healthcare provider credentials and licensure for accuracy and adherence to industry regulations.
  • Processed and reviewed clinical documentation to ensure compliance with organizational and regulatory standards.
  • Maintained accurate data entry and record-keeping in credentialing and healthcare management systems.
  • Coordinated with medical professionals and internal teams to resolve discrepancies in documentation and provider credentials.
  • Processed an average of 200+ medical claims daily, ensuring timely and accurate payment posting.
  • Provided assistance in resolving billing issues between providers, patients and insurance companies.
  • Processed appeals from denied claims as necessary, including gathering additional supporting documentation.
  • Assisted in payment posting, claim adjustments, and account reconciliation to maintain financial accurac.

Senior Provider Relations Representative

Fidelis Care
New York, NY
12.2022 - 05.2024
  • Managed provider credentialing processes, ensuring compliance with company and regulatory standards.
  • Verified provider information (TIN, NPI, licensing, and enrollment status) to ensure accurate claims processing and network participation.
  • Conducted provider education and audits to ensure compliance with credentialing policies and healthcare regulations.
  • Reviewed and analyzed claims discrepancies related to credentialing and enrollment issues before initiating resolution projects.
  • Facilitated Joint Operations Committee meetings with key stakeholders to address credentialing concerns and streamline processes.
  • Cultivated relationships with key stakeholders in the provider community to enhance their understanding of company goals and objectives.
  • Analyzed data related to provider performance, utilization trends, and reimbursement rates to identify areas of improvement.

Intern

New York Presbyterian Brooklyn Methodist Hospital
New York, NY
07.2023 - 11.2023
  • Clinical shadowing with physicians in OR and ER.
  • Assessed patient's need for additional resources such as home health aides or durable medical equipment suppliers in order to provide appropriate level of care.
  • Received patient inquiries or complaints and directed to appropriate medical staff members.
  • Addressed and resolved patient concerns and complaints in a timely and empathetic manner.
  • Obtained informed consent and payment documentation from patients and filed in system.
  • Participated in weekly case conferences with members of the healthcare team for each assigned patient.
  • Managed patient admission and discharge processes, ensuring smooth transitions.

Claims Supervisor

Health Plus
New York, NY
11.2019 - 12.2022
  • Supervised claims processing with a focus on provider credentialing verification, ensuring timely and accurate payment.
  • Managed credentialing-related claim escalations, collaborating with providers and internal teams to resolve discrepancies.
  • Ensured compliance with healthcare regulations by reviewing provider enrollment and credentialing documentation.
  • Led compliance audits to ensure adherence to HIPPA and CMS guideline, reducing claim turnaround time by 30%.
  • Coordinated responses to regulatory inquiries and audits, ensuring timely and accurate compliance reporting.
  • Established strong relationships with external partners, including adjusters, contractors, and medical providers, to streamline claims resolution.
  • Developed and monitored key performance indicators for claims department, driving improvements in processing times and customer satisfaction.
  • Trained billing staff on enrollment validation, documentation accuracy, and claims system navigation.

Pharmacy Technician/Biller

IQVIA
Parsippany, NJ
03.2018 - 11.2019
  • Processed medical claims requiring provider credentialing verification, ensuring accuracy of documentation (EOBs, CMS-1500).
  • Assisted with provider database management, verifying credentials and maintaining up-to-date records for reimbursement eligibility.
  • Coordinated with healthcare professionals to validate provider credentials for claims approval.
  • Performed regular medication audits to ensure compliance with regulatory standards.
  • Enhanced pharmacy efficiency by developing and implementing organizational systems.
  • Ensured compliance with insurance billing guidelines and supported reconciliation efforts to ensure accurate billing.

Engagement Care Specialist

Centene Corporation
New York , NY
05.2017 - 03.2018
  • Making outbound or receiving inbound calls from members to schedule doctor appointments, assisting members that need to complete health needs screenings or making payments to become eligible for enhanced benefits.
  • Influencing members to take advantage of additional benefits available by educating members on enhanced services that are available and recommending preferred Providers.
  • Educating members on utilization of emergency departments in non-emergent conditions and the impact to their benefits.
  • Facilitated member enrollment, service authorization, and eligibility verification for Medicaid/Medicare populations.
  • Identifying and overcoming barriers in order for members to complete needed health screenings, obtain needed services or make payments to secure enhanced benefits.
  • Reviewing each member profile prior to outreach to identify areas of opportunity, which includes but is not limited to reviewing additional benefits available for members and identifying opportunities for members to become eligible for additional benefits.
  • Participating in continuous quality improvement initiatives to ensure department and company goals are met and exceeded.
  • Reviewing and analyzing data for call reports to make adjustments as needed to call approach for members in order to obtain information.
  • Acting as a secondary resource for the Member Services or Provider Services call centers.

Grievance Appeals Specialist

WellCare of New York
New York, NY
01.2016 - 05.2019
  • Examined claims, records and procedures to grant approval of coverage.
  • Used insurance rate standards to calculate premiums, refunds, commissions and adjustments.
  • Conducted research into applicable federal, state, and local labor laws as they relate to grievances and appeals.
  • Assisted claimants, providers and clients with problems or questions regarding claims.
  • Coordinated and planned investigations of claims to confirm compensability and coverage.

Intern

Memorial Sloan Kettering
New York, NY
05.2022 - 07.2022
  • Clinical shadowing with physicians in OR and ER.
  • Liaised effectively with patients, doctors and staff members, assessing medical charts and promoting high level of communication and interaction.
  • Monitored patients' vital signs including temperature, blood pressure, pulse rate, respiration rate, height, weight.
  • Coordinated with insurance companies to confirm patient coverage and process claims.
  • Followed up with discharged patients after they left the facility to ensure they were receiving adequate post-care support.

Intern

NYU Medical Center
New York, NY
05.2021 - 12.2021
  • Verified patients' insurance and payment methods during admissions or check-in processes.
  • Answered incoming calls from patients in a professional manner and responded to inquiries or directed them to appropriate personnel.
  • Supported emergency department registration during peak times, ensuring rapid patient processing.
  • Applied HIPAA privacy and security regulations while handling patient information.
  • Obtained necessary signatures for privacy laws and consent for treatment.
  • Scheduled follow-up visits as needed based on physician instructions.
  • Coordinated with clinical staff to manage patient flow, reducing wait times and improving satisfaction.

Intern

Ann & Robert H. Lurie Children's Hospital of Chicago
Chicago, IL
06.2022 - 07.2022
  • Clinical shadowing with physicians and surgeons in the OR and ER.
  • Clinical shadowing with pediatricians amongst NICU and PICU.
  • Participated in clinical rounds in hospital setting.
  • Assessed patients' conditions through imaging and x-rays.
  • Evaluated patient conditions and determined severity levels; collaborated on next steps for care and treatment plans.

Education

Bachelors of Science - Biology and Health Sciences

Spelman College
Atlanta, Georgia
05.2023

Skills

  • Adaptability
  • Attention to detail
  • Collaboration
  • Communication
  • Discipline
  • Leadership
  • Multitasking
  • Problem-solving
  • Teamwork
  • Time management
  • Denial management and appeals resolution
  • Quality improvement
  • Relationship building
  • Credentialing verification
  • Regulatory compliance
  • Documentation review
  • Compliance monitoring
  • Payment Posting and Account Reconciliation
  • High-volume medical billing and claims processing
  • Enrollment and eligibility verification
  • EHR systems: Epic, Medisoft, etc
  • Microsoft Excel and Data Analysis
  • HIPAA, ICD-10, CPT coding, and CMS compliance
  • Revenue Cycle Operations
  • Customer inquiry and dispute resolution
  • Medicare, Medicaid, and Commercial Payers
  • Accounts Receivable Management
  • Prior authorizations and benefit investigations

References

Will be furnished on demand.

Accomplishments

During the summer of 2023, I participated in the Biostatistics and Computational Biology Research Program at Harvard University’s T.H. Chan School of Public Health. Under the guidance of my research mentor, I investigated the association between preoperative malnutrition and surgical outcomes in young children undergoing ventricular septal defect (VSD) closure in low-resource settings. For your reference, I have included links to a live recording of my presentation, my senior thesis, and my research poster. In the summer of 2022, I was selected to join the inaugural cohort of the HBCU Scholars Program at Northwestern University Feinberg School of Medicine. During this immersive experience, I conducted research focused on public and global health under the guidance of a dedicated faculty mentor. I collaborated with Missing Pieces, a Chicago-based nonprofit that provides bereavement and grief support to families following the loss of a child, adolescent, or young adult. Our team worked in partnership with community organizations to expand access to these critical services across the Chicago area. In addition, I contributed to the distribution of public health resources in local neighborhoods, developed a research poster, and presented our findings as part of the program’s closing symposium.

Certification

Heartsaver First Aid CPR AED | American Heart Association

Affiliations

Spelman NAACP | Volunteer and Community Service

  • Spelman NAACP is the Spelman College chapter of the National Association for the Advancement of Colored People. As part of the NAACP’s Youth & College Division, the organization is committed to promoting social justice, civic engagement, and advocacy for the rights of marginalized communities. It empowers students to take action through education, community outreach, and political activism.

Spelman Health Careers Club | Volunteer and Community Service

  • Spelman Health Careers Club is a student organization that supports Spelman students pursuing careers in health and medicine. The club provides resources, mentorship, and professional development opportunities, including workshops, guest speakers, and networking events. Its mission is to prepare and empower students for success in medical, dental, public health, and other healthcare-related fields.

Spelman MAPs (Minority Association for Pre-Medical Students) | Volunteer and Community Service

  • Spelman MAPS (Minority Association of Pre-Medical Students) is a chapter of the national organization that supports underrepresented students pursuing careers in medicine. The organization offers mentorship, academic resources, networking opportunities, and exposure to healthcare professions to help prepare students for medical school and beyond.

Spelman SOT (Sisters of STEM) | Volunteer and Community Service

  • Spelman Sisters of STEM is a student organization dedicated to supporting and uplifting Spelman students majoring in science, technology, engineering, and mathematics. The group fosters a strong community through mentorship, academic support, professional development, and outreach, empowering women of color to thrive and lead in STEM fields.

SPELReads | Volunteer and Community Service

  • SpelReads is a Spelman College organization dedicated to promoting literacy, a love for reading, and critical thinking through book discussions, community service, and outreach. The group encourages intellectual engagement and fosters a strong reading culture both on campus and in surrounding communities.

Timeline

Care Review Processor

CVS Pharmacy
05.2024 - Current

Intern

New York Presbyterian Brooklyn Methodist Hospital
07.2023 - 11.2023

Senior Provider Relations Representative

Fidelis Care
12.2022 - 05.2024

Intern

Ann & Robert H. Lurie Children's Hospital of Chicago
06.2022 - 07.2022

Intern

Memorial Sloan Kettering
05.2022 - 07.2022

Intern

NYU Medical Center
05.2021 - 12.2021

Claims Supervisor

Health Plus
11.2019 - 12.2022

Pharmacy Technician/Biller

IQVIA
03.2018 - 11.2019

Engagement Care Specialist

Centene Corporation
05.2017 - 03.2018

Grievance Appeals Specialist

WellCare of New York
01.2016 - 05.2019

Bachelors of Science - Biology and Health Sciences

Spelman College
Jaiann Caton