Tia Smith
Houston,US
Summary
Detail-oriented healthcare professional with extensive experience in utilization management, medical claims processing, and provider/member services. Skilled in prior authorizations, medical necessity review, benefits verification, and claims adjudication, with a strong understanding of ICD-10, CPT, HCPCS coding, HIPAA, and CMS guidelines. Adept at collaborating with providers, payers, and patients to ensure accurate claims resolution, compliance, and high-quality service. Seeking to leverage expertise in healthcare operations, customer service, and process improvement to contribute to organizational efficiency and positive patient outcomes.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Utilization Management Representative
Elevance Health
Houston, TX
10.2020 - 05.2025
- Conduct concurrent and retrospective reviews to determine medical necessity and service appropriateness using InterQual/MCG criteria.
- Coordinate with physicians, nurses, and case managers to evaluate clinical documentation.
- Ensure timely processing of authorizations and appeals within regulatory timeframes.
- Educate providers and members on coverage guidelines, benefits, and requirements.
- Maintain meticulous records in compliance with NCQA, URAC, and state/federal guidelines.
- Consistently meet or exceed departmental productivity and accuracy goals.
Claims Processor
Elevance Health
Houston, TX
06.2016 - 10.2020
- Accurately reviewed and processed a high volume of medical, dental, DME, and/or pharmacy claims in accordance with plan benefits, provider contracts, and regulatory guidelines.
- Verified member eligibility, provider status, and coverage policies to determine claim accuracy and appropriateness.
- Applied CPT, ICD-10, and HCPCS coding knowledge to validate clinical data and adjudicate claims properly.
- Researched and resolved complex or denied claims through investigation and coordination with providers, billing offices, and internal departments.
- Maintained high productivity while consistently meeting or exceeding quality assurance benchmarks and turnaround time standards.
- Documented claim activity clearly and thoroughly in claims processing systems (e.g., Facets, Xcelys, & Amysis).
- Ensured compliance with HIPAA regulations and maintained confidentiality of protected health information (PHI).
- Supported audits, appeals, and adjustments by gathering supporting documentation and preparing claim summaries.
Customer Service Representative
Elevance Health
Houston, TX
10.2014 - 06.2016
- Provided high-quality support to members and providers by responding to inquiries related to health insurance benefits, coverage eligibility, claims status, billing, and prior authorizations.
- Accurately interpreted and explained complex plan benefits across Medicare, Medicaid, and commercial products in a clear and empathetic manner.
- Resolved escalated issues by researching claims discrepancies, coordinating with internal departments, and ensuring timely follow-up and resolution.
- Educated members on preventive services, cost-saving programs, and in-network providers to improve care utilization and satisfaction.
- Documented all interactions in CRM and claims processing systems (e.g., Facets, QNXT, HealthEdge) in compliance with HIPAA and organizational guidelines.
- Met or exceeded departmental KPIs including call handling time, first-call resolution, customer satisfaction, and compliance audits.
- Participated in ongoing training to stay updated on policy changes, regulatory requirements, and system enhancements.
Education
Associate of Applied Science - Health Information Technology
DeVry University Chicago Campus
Chicago, IL08.2025
Diploma - Medical Billing And Coding
DeVry University
Chicago, IL11.2023
Skills
- Utilization Management (UM), Prior Authorizations, and Medical Necessity Review
- Medical Claims Processing, Adjudication, and Appeals Resolution
- Healthcare Policy & Compliance (HIPAA, CMS Guidelines)
- ICD-10, CPT, and HCPCS Coding Knowledge
- Insurance Eligibility & Benefits Verification
- Provider & Member Services, Patient Advocacy, and Call Center Support
- Electronic Medical Records (EMR/EHR) Systems (Epic, Cerner, Facets, Availity)
- Data Entry Accuracy, Quality Assurance, and Process Improvement
- Strong Communication, Conflict Resolution, and Customer Service Skills
- Time Management, Multitasking, and Cross-Functional Team Collaboration
Certification
Certified Coding Specialist
Timeline
Utilization Management Representative
Elevance Health
10.2020 - 05.2025
Claims Processor
Elevance Health
06.2016 - 10.2020
Customer Service Representative
Elevance Health
10.2014 - 06.2016
Associate of Applied Science - Health Information Technology
DeVry University Chicago Campus
Diploma - Medical Billing And Coding
DeVry University