Tiara Houston
Waxahachie,TX
Summary
- Over 7 years of experience in Medical Claims, including processing, contract review, benefit analysis, and system configuration.
- Skilled in posting payments, generating Explanation of Benefits (EOBs), and determining member eligibility.
- Proficient in conducting comprehensive research to evaluate, respond to, and resolve Provider Disputes and Member Appeals.
- Experienced in preparing and supporting the development of reports.
- Highly motivated and eager to learn, with strong multitasking abilities and the capacity to prioritize effectively under pressure with minimal supervision.
- Demonstrates excellent judgment and possesses strong written and verbal communication skills.
- Exceptional planning and organizational abilities.
- Proficient in Microsoft Office Suite, QNXT, Epic, WordPerfect, internet research, and general office operations; typing speed of 65+ WPM.
Overview
12
12
years of professional experience
Work History
Patient Access Specialist- PRN
Parkland Health System
06.2022 - Current
- Greets patients, family members, peers, and leadership in a professional, friendly, and respectful manner to promote a positive public image of Parkland. Willingness to move about the system to ensure all facets of the job responsibilities are completed accurately and timely to support the needs of the organization. Required to assist the hospital in the event of an internal or external disaster.
- Maintained patient confidentiality by adhering to HIPAA guidelines and hospital policies.
- Obtain, verify, and update accurate demographic, financial, and insurance information in the process of registration. Including the entry of patient/guarantor information in the patient registration/accounting systems. Ensure accounts are billed accurately and timely. Guarantee that medical record numbers are not duplicated, or overlays created.
- Review patient accounts for financial status to identify non-funded and/or under-funded patients. Initiates preliminary financial counseling screening by reviewing the current residency status, income, employment, and insurance eligibility. If insurance is available, complete validation of coverage and collect copayment as identified. If insurance is not available, explain and offer a PFA/SPCD application to initiate a funding resource. Patient balance may require an estimate of costs for services and a payment plan to be established for the patient.
- Educate patients about financial liabilities, employs proper, compliant patient liability collection techniques before, during and after date of service. Performs cash reconciliation and secured payment entry in adherence to financial and cash control policies and procedures.
- Clearly document actions taken in account notes to ensure information is available and understandable for other departments to review. Track productivity/quality and provides cumulative reports daily, weekly, and monthly as required. Ensures Patient Rights & Responsibilities.
Benefit Configuration Analyst II
Christus Health Plan
12.2021 - Current
- Under the supervision of the Configuration Manager, the Benefit Configuration Analyst I will work in conjunction with, Claims, Network, Provider Data, Utilization Management, as well as other operational departments to ensure validation and quality assurance of benefit, contract, reimbursement, and overall financial analysis that arise during the overpayment identification and recovery process.
- Identify, analyze, and interpret trends or patterns in complex data sets.
- Benefit research, design, configuration, testing, and implementation for multiple product lines including Medicare, Commercial, Exchange, and Tricare
- Research and resolution of defects related to UB04 and HCFA claims.
- 3. Review, validate and load all codes for claims adjudication (ICD10, CPT9, HCPCS, Modifiers, HIPPS, DRG, etc.)
- 4. Configure coding exceptions and maintain the accuracy of clinical editing software (ex. Claim Check)
- 5. Locate, research, comprehend, and appropriately apply 3rd party payer rules and regulations; analyze and resolve complex coding related claim denials in a manner that ensure accurate and optimal reimbursement.
- 6. Coordinates with other departments to gather configuration requirements and provide feedback on change feasibility.
- 7. Gathers and analyzes business requirements to determine the best approach for configuration design and implementation.
- 8. Perform root cause analysis on benefit configuration set-up issues across all lines of business, documents results and present business impact analysis to management.
- 9. Demonstrate strong decision making and problem-solving skills.
Appeal and Grievances Specialist
Kupplin Soal Technologies (Temp agency)
07.2021 - 12.2021
- Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests.
- Review and respond to complaints, grievances and appeals within the stated time frame for each request.
- Ensure 95% compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by adhering to all state and federal regulations.
- Analyze and resolve customer inquiries by adhering to CMS guidelines and CHRISTUS Health Plan internal policies and procedures.
- Actively communicate with other associates to guarantee accurate and timely responses to inquiries involving internal/external customer needs.
- Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary.
- Certify that providers and members are reimbursed accordingly using Medicare or other applicable plan reimbursement policies and procedures.
- Maintain accurate and timely responses to inquiries and generate appropriate letters to members and providers informing them of appeals/grievance decisions.
- Provide recommendations and direction to both servicing providers and members in attempt to eliminate repeated disputes between providers and CHRISTUS Health Plan.
- Follow the CHRISTUS Health guidelines related to Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
Claims Management Analyst
Children's Health
05.2019 - 12.2020
- Resolve complex pended claims, duplicate claims and adjustments.
- Process claims, involving communications with participating plans and/or Service Units.
- Resolve various issues.
- Research and identify other insurance, Medicare, Medicaid and update patient file as needed.
- Coordinate benefits; request explanation of benefits as needed.
- Maintain a working understanding of medical terminology and CPT, HCPCS, and ICD9 coding.
- Read appropriate files in IMAGE and apply information to claims as needed using the Financial Suspense System (FSS).
- Assist with testing system changes and enhancements.
- PC Skills (Word, Excel and E-Mail).
- Monitor treatment in accordance with settlement and UR (35%).
Risk Adjustments Regional Associate
Molina Healthcare Inc.
08.2018 - 03.2019
- Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
- Accept and thoroughly and skillfully complete special projects as assigned.
- Positive attitude when dealing with members of the general public.
- Ability to meet performance standards, including call quotas.
- Excellent verbal and written communication skills.
- Ability to learn internal/external systems.
- Strong familiarity with Microsoft Office.
- Strong organization and process management skills.
- Research and resolve contact information discrepancies for various member populations.
- Outreach to members and schedule an Annual Comprehensive Exam with appropriate provider.
- Learn fundamentals of risk adjustment activities.
- Other duties as assigned.
- Developed and implemented strategies to increase customer satisfaction and engagement.
Appeals Inquiry D/A Resolution Specialist
Molina Healthcare Inc.
12.2016 - 08.2018
- Reviewed contract, post payment and send out EOB.
- Point of contact for submission/resolution of Provider Disputes and/or Member Appeals /or State Complaints Resolutions.
- Assessed and completed appropriate documentation for tracking/trending data.
- Conducted all pertinent research in order to evaluate, respond and close incoming Provider Disputes and/or Member Appeals accurately, timely and in accordance with all established regulatory guidelines inclusive of appropriate review of claims and prior claim payment history.
- Interface with internal departments and external resources and organizations.
- Prepare and assist with reports for unit.
- Maintain confidentiality as required.
Member Service Rep II
Molina Healthcare Inc.
07.2014 - 12.2016
- Responded to incoming calls from members and providers required for meeting departmental goals and individual performance metrics.
- Achieved individual performance goals as it relates to call center objectives.
- Engaged and collaborated with other departments as applicable.
- Complied with workplace safety standards.
- Proficient in discussion and execution of Molina's policies and procedures in accordance with regulatory requirements.
- Demonstrate positive working relationships with peers and effectively manage conflict.
- Attended meetings and training sessions as scheduled.
- Show flexibility in meeting changing performance objectives consistent with Molina and department objectives.
- Seek out work during slow times to help ensure that department goals were met.
- Assisted with formal training needs of new employees as needed.
- Took responsibility for keeping up-to-date and develops skills to meet new needs.
- Pursued learning opportunities to develop and broaden skill set and expertise.
- Gathered information to critically evaluate options, seeking alternative perspectives to identify root causes and develop solutions.
- Handled escalated calls on behalf of management.
- Completed research for state, legislative or regulatory inquiries as applicable within established timelines.
- Processed pending guardianship documentation received from members and coordinating an approval with corporate compliance via the Champ (Health Plan) system.
- Responsible for processing simple claim adjustments as specified.
- Supported Q&A for the department and other responsibilities as needed.
- Skills: Claims Processing (Medicaid & Medicare), Familiar with multiple databases such as Qnxt, Alchemy, and Emdeon. Customer Support, Medical Billing, and Customer Communications.
Provider Services Representative
Aetna
03.2013 - 07.2014
- Reviewed all claim inquiries and applies processing rules to determine allowable benefits for payment.
- Reviewed services for appropriateness of charges and considers system edits.
- Determined exclusions and denials based on contract provisions.
- Suspend claims requiring additional information and/or special handling; initiates action to obtain required information.
- Forwarded claims requiring external department intervention to the appropriate department or person.
- Monitored outstanding inquiries and worked with management staff to identify and resolve areas of non-compliance.
- Serviced calls and correspondence from members and/or providers; identified and/or responded to inquiries, dissatisfactions, complaints and grievances.
- Documented all calls in inquiry tracking system.
- Using established protocols ensures resolutions provided are presented in a clear and accurate manner.
- Facilitated problem resolution and acts as customers advocate.
- May perform initial research of member/provider issues.
- Reconciled plan information utilizing department-generated procedures and reference materials.
- Utilized internal and external systems to update modify and extract member/provider information.
- Followed internal process and procedures to ensure activities are handled in accordance with departmental and company policies/procedures.
- Performed initial research of member/provider issues; explained claims, appeal, grievances, etc. procedures.
- Within the parameters of job duties, utilizes internal and external systems to update, modify and extract member/provider information.
- Reviewed phone activity and quality reports to self-monitor performance, quality and productivity standards.
- Discussed deficiencies/problems with the supervisor to adjust behavior and work activities as appropriate.
Education
Diploma -
David W. Carter High School
Dallas, TX05.2007
Some College (No Degree) -
Cedar Valley Community College
Lancaster, TXSkills
- Claims Processing (Medicaid & Medicare)
- Familiar with multiple databases such as Qnxt
- Familiar with multiple databases such as Alchemy
- Familiar with multiple databases such as Emdeon
- Customer Support
- Medical Billing
- Customer Communications
- Medical terminology
- HIPAA compliance
- Professionalism and ethics
- Exceptional communication
- Insurance billing
- Front desk operations
Timeline
Patient Access Specialist- PRN
Parkland Health System
06.2022 - Current
Benefit Configuration Analyst II
Christus Health Plan
12.2021 - Current
Appeal and Grievances Specialist
Kupplin Soal Technologies (Temp agency)
07.2021 - 12.2021
Claims Management Analyst
Children's Health
05.2019 - 12.2020
Risk Adjustments Regional Associate
Molina Healthcare Inc.
08.2018 - 03.2019
Appeals Inquiry D/A Resolution Specialist
Molina Healthcare Inc.
12.2016 - 08.2018
Member Service Rep II
Molina Healthcare Inc.
07.2014 - 12.2016
Provider Services Representative
Aetna
03.2013 - 07.2014
Diploma -
David W. Carter High School
Some College (No Degree) -
Cedar Valley Community College
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