Tishima Goldston
Summary
Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
27
27
years of professional experience
Work History
Senior Appeals Analyst
UnitedHealth Care, UnitedHealth Group
05.2012 - Current
- Research and resolve written and online complaints submitted by physicians and hospitals
- Ensure complaints have been categorized correctly
- Obtain additional documentation required for case review if needed
- Review case to determine if review by a clinician is required
- Send letter correspondences to providers with determination of appeal
- Review, analyzed and processed complex grievances and appeals.
- Followed department guidelines, standard operating procedures, and reimbursement policies to conduct reviews.
- Assist new hires with on the job training
- Use UHG technology to track, route, and retrieve information as well as access key databases. Access Microsoft Teams and Microsoft Outlook for incoming email
- Utilize Network Database, Escalation Tracking System, and UNET to verify provider's and member's information is accurate in our system.
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
National Rapid Resolution Expert
UnitedHealth Care, UnitedHealth Group
02.2008 - 04.2012
- Respond to escalated member and providers calls
- Resolve problematic types of customer service inquires
- Process Claims
- Send written correspondence to providers and members concerning inquires
- Assist doctors with analyzing their contracts and the processing of medical claims.
- Research member's medical plan and mental health plans
- Served as a team lead to new hires, assisting them with any questions or concerns pertaining to their job descriptions
- Skilled at working independently and collaboratively in a team environment.
- Monitor Customer Care Professional phone calls for quality and give them positive feedback on how to obtain higher quality scores and provide our customers with excellent customer Service
- Self-motivated, with a strong sense of personal responsibility.
- Excellent communication skills, both verbal and written.
Professional Provider Analyst /Customer Care Professional
UnitedHealth Group
07.2002 - 02.2008
- Helped large volume of customers every day with positive attitude and focus on customer satisfaction.
- Responded to customer needs through competent customer service and prompt problem-solving.
- Assisted call-in customers with questions.
- Navigated multiple computer systems and applications to find information.
- Print and mail letter correspondences
- Handle various products: USS Key Accounts and CDHP
- Make conference calls with members and providers to get balance billing issues resolved
Senior Sales Associate
Dunn & Bradstreet
10.1999 - 12.2001
- Trained, coached, and mentored new sales associates for maximum performance.
- Met or exceeded sales objectives on consistent basis to drive company growth.
- Trained new sales personnel on company policies, customer acquisition strategies and successful sales techniques.
- Developed sales plans to increase market share, customer base and revenue.
- Update business records for companies
Customer Service Representative Team Lead
Infonxx
05.2000 - 05.2001
- Handled day-to-day customer contact via phones, faxes, and emails.
- Assist consumers with directory assistance calls
- Resolved escalated customer service inquiries and complaints to maintain satisfaction.
- Monitored customer service calls to verify representatives' adherence to service standards and best practices.
- Supervised large teams with guidance, support and direction for high-quality customer care.
Cashier Supervisor
Tj Maxx Dept Store
01.1997 - 10.1999
- Built positive relationships with customers to increase repeat business.
- Quickly and accurately counted drawers at start and end of each shift.
- Trained and coached cashier team members on checkout procedures and strategies to maximize customer satisfaction.
- Backed up cashiers and customer service employees on questions such as rules on refunds and defective items.
Education
Bachelor of Arts - Communication Studies
North Carolina A & T State University
Greensboro, NC05.2012
Skills
- Medical Record Assessment
- Extensive Research
- Claims Reviewing
- Appeals Support
- Benefits Review
- Determine Coverage
- Sourcing and Compiling Information
- Liability Determinations
Timeline
Senior Appeals Analyst
UnitedHealth Care, UnitedHealth Group
05.2012 - Current
National Rapid Resolution Expert
UnitedHealth Care, UnitedHealth Group
02.2008 - 04.2012
Professional Provider Analyst /Customer Care Professional
UnitedHealth Group
07.2002 - 02.2008
Customer Service Representative Team Lead
Infonxx
05.2000 - 05.2001
Senior Sales Associate
Dunn & Bradstreet
10.1999 - 12.2001
Cashier Supervisor
Tj Maxx Dept Store
01.1997 - 10.1999
Bachelor of Arts - Communication Studies
North Carolina A & T State University
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