Summary
Overview
Work History
Education
Skills
Timeline
Generic

Tiffany Wallace

Summary

Service-focused professional bringing unparalleled skills in customer relations, task prioritization & time management. Motivated to directly and efficiently address customer concerns head-on, develop proactive solutions and implement corrections with efficiency . Offering keen attention to detail and strong decision making skills to manage multiple, concurrent tasks. Motivated to maintain
customer satisfaction and contribute to company success. Experienced Medicare/Medicaid Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 5+ years of experience and willingness to take on any challenge. Highly trained professional with a background in verifying insurance benefits and creating appropriate patient documentation. An established Insurance Verification Specialist known for handling various office tasks with undeniable ease. Experienced Medicaid/Medicare Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 5+ years of experience and willingness to take on any challenge. Experienced Medicaid/Medicare Insurance Specialist successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 5+ years of experience and willingness to take on any challenge.

Overview

10
10
years of professional experience

Work History

Appeals Specialist

Centene (Formally)-WellCare Health Plans
12.2018 - Current
  • Responds to phone calls regarding questions from providers, customers and community members who needs relates to clinical denial and appeal functions.
  • Accurately log, track and ensure completion of all appeals and grievance cases in compliance with contract service standards.
  • Resolved medical claims by approving or denying documentation, calculating benefit due and initiating
    payment or composing denial letter.
  • Provide excellent customer service to internal and external customers. Follow up in a timely manner with professionalism and enthusiasm

Configuration Specialist

PCMA
12.2018 - 03.2020
  • Analyzed existing systems and databases and recommended enhancements to solve business needs
  • Implemented change control, configuration status accounting and configuration audits.
  • Kept CM work aligned with project's configuration management plan.
  • Communicated and explained business requirements to team members to understand and implement functional demands.

Denials Advocate

Cognizant Technology Solutions
05.2016 - 12.2018
  • Adhere to payer guidelines for appeals submission and escalate exhausted appeal efforts for resolution
  • Assist in data gathering and reporting of non authorizations, appeals and provider disputes.
  • Follow-up on all outstanding insurance claims, which include correspondence, denials and rebills.
  • Prepare reviews for cases that do not meet the required criteria and Maintain files and logs related to all appeals.

DME Care Coordinator

HealthPlan Services
11.2015 - 03.2016
  • Determined need for special assessment activities for complex cases, effectively handling care plans.
  • Optimized customer support by establishing collaborative service environments through targeted operational initiatives.
  • Answered customer questions via telephone, email and live chat services.
  • Responded to customer requests, offering excellent support and tailored recommendations to address needs.

Insurance Verification Specialist

WellCare Health Plans Inc
01.2014 - 06.2015
  • Completed administrative patient intakes with case histories, insurance information and mandated forms.
  • Generated reports to track insurance verifications and claim progress.
  • Conducted patient intake interviews, recording and documenting relevant information.
  • Communicated verification and authorization status updates with clinical department to facilitate decision-making for patient admissions and insurance coverage.

Education

High School Diploma -

Bloomingdale High School
Valrico, FL

Skills

  • Complex Claims
  • Billing Resolutions
  • Information Updates
  • Appeals/Denials
  • Explanation of Benefits review
  • Research and investigation
  • Case management
  • Senior Leadership Support
  • Grievance handling
  • Documentation abilities
  • Data Configuration
  • ICD-9 Coding
  • Eligibility Verification
  • Claim Processing
  • Provider Relations
  • Fee Schedule
  • Auditing Proficiency
  • Medicare and Medicaid
    Processes
  • Collaborative relationships
  • Team Building
  • Data entry proficiency
  • Organizational abilities
  • Continuous learning mindset
  • Professionalism and Ethics
  • HIPAA Compliance Knowledge
  • Medical coding knowledge
  • Appeals Process Proficiency
  • Insurance Policies Understanding
  • Teamwork and Collaboration
  • Customer Service
  • Attention to Detail
  • Organizing and Prioritizing Work
  • Critical Thinking
  • Active Listening
  • Decision-Making
  • Claims Processing
  • Microsoft Office
  • Documentation skills
  • Data Entry
  • Claims adjustment
  • Excellent administrative abilities
  • Prior authorization processing
  • Policy Review
  • Coverage Determination
  • Documentation processing
  • Insurance Coverage Verification
  • Medicaid knowledge
  • Understanding of medical terms
  • Eligibility Determination
  • Policy analysis
  • Application Review
  • Information Verification
  • Patient contact
  • New Policies Processing
  • 10-Key Touch

Timeline

Appeals Specialist

Centene (Formally)-WellCare Health Plans
12.2018 - Current

Configuration Specialist

PCMA
12.2018 - 03.2020

Denials Advocate

Cognizant Technology Solutions
05.2016 - 12.2018

DME Care Coordinator

HealthPlan Services
11.2015 - 03.2016

Insurance Verification Specialist

WellCare Health Plans Inc
01.2014 - 06.2015

High School Diploma -

Bloomingdale High School
Tiffany Wallace