TULA RANDALL
Huntington Beach,CA
Summary
Thorough Claims Resolution Specialist skilled handling basic and complex claims with accuracy and efficiency. Good communication, organizational and problem-solving abilities, Strong customer service background,Highly motivated team player.
Overview
29
29
years of professional experience
Work History
Claims Resolution Specialist
Zinnia Healthcare
06.2022 - Current
- Continuously evaluate and work A/R balances
- Follow up on timely filing and loss of revenue from denials and missed opportunities on secondary filings
- Identify claim denial reasons, eligibility discrepancies and billing errors and resolve them in a timely fashion to ensure prompt payment of claims
- Inquiries and follow-up on all denied and unpaid insurance claims
- Accurately and efficiently processes requests for denied claims information using website portals and outbound phone calls for all payers
- Resolve issues related to coding
- Appeals 1st and 2nd level.
HEDIS Pursuit Agent
Aston Carter
03.2020 - 05.2022
- Assignment with SCAN Health plan
- Collection, abstraction of annual HEDIS data
- Includes researching member/provider data.
Representative Payee Specialist
Mental Health Associates of Orange County, MHAOC
08.2018 - 11.2018
- Provide payment for all living expenses and allowance on a weekly to monthly basis for mental health/homeless clients,SSI/SDI Liaison, general office support
Population Management Support Coordinator
Kaiser Permanente, Cancer Outreach
07.2010 - 11.2011
- Tracking of patient population to obtain statistical information related to specific program goals associated with health care management
- Reviewed medical records related to specific care gaps
- Care management reporting, distribution of education materials
- Contacted patients reinforcing self-care management 3/19/22, 4:40 PM Indeed Resume https://my.indeed.com/resume/editor 3/6
- Acted as liaison between patient community and other care related resources
- Structure
Owner
Teeze Boutique
12.2006 - 02.2009
- Daily store operations, customer care, marketing, promotions, buying, visual display, merchandising and reporting, stock and inventory competitive analysis, financial reporting, budget management, payroll
- Interpreting trends to facilitate planning for future sales volume to maximize profit.
Appeals and Grievances Coordinator
Monarch Healthcare Management
10.1999 - 08.2002
- Provided outreach for additional information for appeals and grievances.
- Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Submitted verbal and written notification to members and providers.
Placement Coordinator/Discharge Planner
UCI Medical Center
04.1997 - 08.1999
- Solved problems related to abrupt changes in discharge, coordinated updates and communicated discharge plans.
- Facilitated timely referrals to alternate levels of care and assisted family or guardian with completion of applications.
- Worked with utilization review to establish prior authorization for timely discharges.
- Communicated with referral providers about new referrals and verified receipt of necessary information prior to arrivals.
Utilization Review Coordinator
UCI Medical Center
06.1994 - 04.1997
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Supervised and maintained all utilization review documentation through EZ-Cap.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Education
Medical Assisting Program Certificate -
Huntington Beach Adult School
03.2022
High School Diploma - undefined
Katella High School
06.1984
Skills
- Medical Assistant
- Good understanding of
- CPT,ICD-9, ICD-10,Rev and HCPC codes
- Experience with EZ-Cap, Epic, Practice Fusion CMD, Kipu systems and Cotiviti-Quality Reporter,
- Provider Portals
- EMR Certification
- BLS for Healthcare Providers
- Medical Terminology Certification
- Complete understanding of HIIPA regulations and compliance
- Strong knowledge of HEDIS/NCQA, CM, UR,UM and managed care
- Proficient in Microsoft Suite applications and Google applications
Timeline
Claims Resolution Specialist
Zinnia Healthcare
06.2022 - Current
HEDIS Pursuit Agent
Aston Carter
03.2020 - 05.2022
Representative Payee Specialist
Mental Health Associates of Orange County, MHAOC
08.2018 - 11.2018
Population Management Support Coordinator
Kaiser Permanente, Cancer Outreach
07.2010 - 11.2011
Owner
Teeze Boutique
12.2006 - 02.2009
Appeals and Grievances Coordinator
Monarch Healthcare Management
10.1999 - 08.2002
Placement Coordinator/Discharge Planner
UCI Medical Center
04.1997 - 08.1999
Utilization Review Coordinator
UCI Medical Center
06.1994 - 04.1997
Medical Assisting Program Certificate -
Huntington Beach Adult School
High School Diploma - undefined
Katella High School
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