Tralonda Biddle-Boggues
Las Vegas
Summary
Seasoned Healthcare professional with a proven track record in clinical data analysis and project management. Excelled in enhancing HEDIS measure expertise and healthcare management, achieving significant quality improvements. Known for high productivity and efficient task completion. Excel at analytical problem-solving, communication, and adaptability to ensure thorough and accurate audits. Committed to upholding integrity and transparency in all claims auditing processes.
Overview
10
10
years of professional experience
Work History
Insurance Follow-Up Specialist
Comprehensive Cancer Center of Nevada
Las Vegas
06.2023 - 01.2024
- Analyzed denials received from insurance companies and identified solutions for resolution
- Compiled statistical data related to denied or underpaid claims for management review
- Adhered to HIPAA regulations regarding the confidentiality of patient information
- Provided timely follow-up on insurance claims to ensure accuracy and completeness of information
- Audited medical records for accuracy prior to submission of claims for reimbursement
- Conducted regular audits on all incoming claims submissions for accuracy prior to processing them into system databases
- Developed comprehensive appeals letters to be submitted to various health plans, utilizing in-depth knowledge of medical billing regulations
- Identified trends in denials received from carriers which could lead to improved performance within the department
Case Care Management Assistant, HEDIS Specialist
Healthcare Support Staffing
Maitland
12.2017 - 12.2022
- Executed various administrative responsibilities supporting Care Management functions.
- Provided feedback about audit processes in order to improve overall efficiency.
- Met needs of physicians and other treating team members with timely retrievals of patient medical records.
- Drafted statistical reports related to diseases treated, surgeries performed and hospital bed occupancy
- Conducted comprehensive review of medical records for HEDIS compliance.
- Researched and clarified coding discrepancies in accordance with established guidelines.
- Improved integrity and completeness of medical records by consulting with clinical staff to resolve coding and diagnostic mistakes.
- Compiled statistical reports summarizing audit results for management review.
- Conducted system analysis and testing to identify and resolve technical issues or inefficiencies.
- Participated in training sessions aimed at increasing understanding of HEDIS protocols.
- Generated periodic and ad hoc reports outlining statistics, narrative findings or graphical representations of health information.
- Monitored compliance with regulatory standards for the Clinical Documentation Improvement program.
- Completed in-depth audits of performance and quality of current charts and processes through facility reviews.
Claims Examiner-Healthcare
Durham Staffing/Apollo MD
Atlanta
02.2017 - 10.2017
- Worked with Centricity and Athena; Reviewed and processed accounts via the 3rd party
- Scrubbed claim edits that have either denied or are within timely filing
- Aged detail report for the following aging buckets, greater than 90 & greater than 150 days
- Posted payments via EOB's and resubmit claims via electronic or manual billing
- Called insurance companies to determine status of claim payment and insurance verification
- Created written communication regarding claims research, analysis outcomes
Refunds Analyst/HEDIS
Medsynergies
Irving
11.2015 - 09.2016
- Worked for HEDIS 2015 project doing research and investigation per charts assigned
- Reviewed and analyzed electronic medical records for billing purposes
- Utilized Epic to investigate and adjudicate medical claims via electronic and manual billing
- Reviewed refund demand letter request within 10 days to eliminate offsets
- Initiated refunds or identify overpayments to clear credit balance
- Researched returned hospital refund checks and apply voids to accounts and reissue refunds
- Reviewed reimbursements worksheets with to resolve credit balances
- Researched possible refund adjustments per government payers
- Determined funds are disbursed to the insurance carrier or patient
- Determined COB to ensure correct adjustments and initiate refund
Charge Entry Specialist-Healthcare
Atlanta
10.2014 - 08.2015
- Billed all claims via UB and 1500 via Facets billing system; Utilized Trizetto Facets 4.7/EDI
- Researched and analyze if claims were paid correctly demonstrating 100% accuracy
- Responsible for all written communication regarding claims research, analysis and outcomes
- Utilized appeals database, provider dispute letters, claims worksheets and email responses
- Verified insurances website to ensure the claim is paid correctly per patient
- Corrected claims 90 days or older via electronic billing; Utilized Posted payments per EOB line item to ensure payment were correct via fee insurance fee
Reimbursement Specialist
West Corporation
Omaha
08.2014 - 11.2014
- Assisted in recovering aged accounts via Citrix edit reports for denied and duplicate claims
- Made calls to insurance companies to determine status of claim payment and insurance verification
- Researched and prepared refund reports on excel spreadsheets for weekly accounts receivables
- Performed general clerical function for updating patient demographics
- Interpreted and processed EOB's, researched and appealed denied claims, resubmit corrected claims
- Monitored client accounts receivable, and access carrier websites for claims status
Education
Certificate of Technical Studies - Project Management
Metropolitan Community College
Omaha, NE02-2025
Diploma -
Central High School
NE05-1994
Skills
- Clinical data analysis
- Clinical Research experience
- Healthcare management
- Audit preparation
- Data collection techniques
- Medical record review
- Quality improvement initiatives
- HEDIS measure expertise
- Risk assessment
- Project management
- Electronic medical record software
- MEDITECH EHR software
- Epic Software
- Athena Software
- Nextgen Software
- EClinicalWorks
- AdvancedMD
References
References available upon request.
Timeline
Insurance Follow-Up Specialist
Comprehensive Cancer Center of Nevada
06.2023 - 01.2024
Case Care Management Assistant, HEDIS Specialist
Healthcare Support Staffing
12.2017 - 12.2022
Claims Examiner-Healthcare
Durham Staffing/Apollo MD
02.2017 - 10.2017
Refunds Analyst/HEDIS
Medsynergies
11.2015 - 09.2016
Charge Entry Specialist-Healthcare
10.2014 - 08.2015
Reimbursement Specialist
West Corporation
08.2014 - 11.2014
Certificate of Technical Studies - Project Management
Metropolitan Community College
Diploma -
Central High School
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