Theresa Baum
Palm Harbor,FL
Summary
To secure a position that will utilize my extensive background in the healthcare and insurance industry involving grievance and appeals, claims examining, case management, coding, billing, business configuration, project management and customer service.
Overview
23
23
years of professional experience
Work History
Provider Payment Reconsideration Analyst I
Elevance Health
06.2011 - 04.2025
- Examines Medicaid claims for the Texas and Iowa members in accordance with plan policies and provisions.
- Communication in writing with providers, internal customers and other sources as needed to gather information to process claims and complete disputes.
- Corresponds and communicates with providers.
- Logs, tracks and processes provider disputes forwarded to the Provider Payment Reconsideration Unit.
- Maintains all documentation associated with the processing and handling of provider disputes to comply with the regulatory standards while maintaining an accurate and complete dispute record in the electronic data base.
- Conducts dispute research and filing including, but not limited to, requesting member medical records, organizing documentation, preparing written summaries to present to the Clinical Department, Health Plan, Medical Coding Department, Root Cause Configuration Unit as well as the Enrollment and Provider Data Management Unit for dispute resolution.
- Compose dispute resolution letters for the provider.
- Ensures thorough and timely completion and accuracy of each dispute case within the required turnaround time (TAT).
- Assists other Markets to load balance when necessary to assist in maintaining a low inventory and completing cases with in the required turnaround time.
Grievance and Appeals Coordinator
Physicians United Plan
Orlando, Florida
11.2007 - 06.2011
- Corresponds and communicates with providers, members or members representatives.
- Logs, tracks and processes appeals and grievances forwarded to the Grievance and Appeals Department.
- Maintains all documentation associated with the processing and handling of the appeals and grievances to comply with the regulatory standards while maintaining an accurate and complete appeals/grievance record in the electronic data base.
- Conducts general appeal research and filing including, but not limited to, requesting waivers of liability and/or appointment of representative forms, requesting member medical records, organizing documentation, preparing written summaries to present to the Medical Director and/or Senior Management, documentation of the appeal resolution.
- Prepares and sends completed case files to the IRE, MAXIMUS, Federal Services.
- Prepares and presents cases to the Administrative Law Judge (ALJ).
- Researches grievances and reviews with the appropriate departments such as Provider Relations, Marketing and/or Member Services to provide a satisfactory and timely resolution.
- Maintain files on each grievance/appeal case.
- Compose grievance and appeal response letters for the member/provider.
- Ensures thorough and timely completion and accuracy of each grievance/appeal case.
- Conducts research and provides timely resolution to grievances that are received via the CMS Complaints Tracking Module (CTM) and Florida Department of Financial Services.
- Conducts weekly audits of the grievances opened and resolved on first case resolution by the Member Services Department and provides feedback and education to the representatives to ensure that grievances are classified correctly to ensure accurate reporting.
- Provides grievances/appeal trends to Senior Management.
- Complies and submits quarterly grievance/appeal reports to the Quality Steering Committee (QMSC) and the Center Of Medicare and Medicaid (CMS).
- Participated in the 2008 and 2010 URAC audit.
- Participated in the 2011 CMS Data Validation Audit.
- Was awarded the 2010 Employee of the Quarter (Qtr 2).
Claims Analyst II
Amerigroup
Tampa, Florida
02.2007 - 07.2007
- Examine, coding and inputting, of Medicaid claims for the Florida and Tennessee members in accordance with plan policies and provisions.
- Communication on the phone or in writing with providers, internal customers and other sources as needed to gather information to process claims.
- Researched and completed large adjustment projects pertaining to incorrect business configuration and fee schedules.
Configuration Specialist
WellCare Health Plans
Tampa, Florida
07.2006 - 02.2007
- Configured and loaded participating provider contracts for the Florida, New York and Georgia Medicare and Medicaid lines of business.
- Researched and completed special projects ensuring providers were reimbursed in accordance with all contractual provisions.
- Handled contractual amendments involving both real and retro changes.
Member Service Coordinator
Horizon Blue Cross and Blue Shield of New Jersey
Wall, New Jersey
03.2004 - 06.2006
- Examine, coding and inputting, of group health claims in accordance with plan policies and provisions.
- Ensure that claims are settled satisfactorily and that favorable relationships with customers are maintained.
- Utilize current managed care guidelines to add services to referrals/authorizations in order to reflect the appropriate level of care.
- Communicate with providers and participants to resolve managed care and case management issues and to incorporate managed care negotiated rates into the claims process.
- Communication on the phone or in writing with customers, providers, plan employees and other sources as needed to gather information to process claims and maintain good business relationships.
- Point person for reinstatements.
- Responsible for the processing of excess charge claims, psychiatric claims, internal reviews and Premium paid to date claims.
Billing Specialist/Surgical Coordinator
Affiliated Foot and Ankle Center
Ocean, New Jersey
05.2002 - 01.2004
- Responsible for running front desk.
- Coordinated authorization and referral process for all scheduled surgical procedures.
- Completed all necessary pre admission information for patients prior to surgery.
- Responsible for billing and coding required insurance forms all services rendered.
- Communication with insurance carriers regarding payments and denials.
Education
Certified PCA -
Monmouth County Vocational School
High School -
Howell High School
Howell, New JerseySkills
- Windows
- Lotus Notes
- Microsoft Office
- ERISCO
- QBLUE
- NASCO
- SARS
- UPS
- SRPT
- UCSW
- IMAGE PLUS
- DIAMOND
- SIDEWINDER
- CACTUS
- FACETS
- MACESS
- SOAP
- EZ CAP
- Voyager
- Prescription Solutions
- HPMS Portal
- Marx
- Nexgen
- Citrix
References
Available upon request.
Timeline
Provider Payment Reconsideration Analyst I
Elevance Health
06.2011 - 04.2025
Grievance and Appeals Coordinator
Physicians United Plan
11.2007 - 06.2011
Claims Analyst II
Amerigroup
02.2007 - 07.2007
Configuration Specialist
WellCare Health Plans
07.2006 - 02.2007
Member Service Coordinator
Horizon Blue Cross and Blue Shield of New Jersey
03.2004 - 06.2006
Billing Specialist/Surgical Coordinator
Affiliated Foot and Ankle Center
05.2002 - 01.2004
Certified PCA -
Monmouth County Vocational School
High School -
Howell High School