VENIVEA SMITH
Houston
Summary
Claims Analyst focused on claims workflows, EDI transaction validation, and payment integrity review across CMS-regulated environments, with 90% to 98% of claims review findings leading to confirmed correction steps. Brings root cause analysis and SQL-supported investigation to identify adjudication defects, reimbursement variances, and processing errors that affect claims accuracy. Also documents findings clearly and works across business and technical teams to support remediation and workflow updates.
Overview
2
2
Certifications
10
10
years of professional experience
Work History
Senior Test Engineer / Technical Trainer
Gainwell Technologies
Houston, TX
02.2024 - 11.2025
- Resolved 50 claims defects per sprint through comprehensive research and root cause analysis.
- Validated 837I and 837P transactions to confirm accurate claims intake, processing, adjudication, and reimbursement.
- Analyzed 835 ERA files to verify payment accuracy, adjustment codes, denial reasons, reimbursement calculations, and provider payment outcomes.
- Validated Medicaid business rules, payment integrity controls, claims edits, DRG calculations, and reimbursement logic.
- Supported claims remediation and reprocessing by identifying root causes and documenting defects for follow-up action.
- Contributed to workflow documentation and requirements validation to improve collaboration between business and technical teams.
PMO Analyst (Special Assignment)
Gainwell Technologies
Houston, TX
03.2025 - 09.2025
- Audited time reporting and contractor billing records for more than 100 consultants supporting Medicaid projects.
- Identified reporting discrepancies, compliance concerns, and invoicing inaccuracies requiring corrective action.
- Coordinated onboarding activities for project stakeholders across active Medicaid workstreams.
- Managed stakeholder communications and escalation follow-up to keep issues moving toward resolution.
- Improved operational reporting accuracy through detailed analysis and process oversight.
Senior Provider Service Advocate / Subject Matter Expert (SME)
UnitedHealthcare Group
Houston, TX
10.2022 - 02.2024
- Analyzed complex claims and billing workflows by reviewing provider contracts, reimbursement methods, business rules, and benefit configurations.
- Led root cause analysis of claim denials, remittance issues, and payment variances with internal and external stakeholders.
- Created and maintained documentation for claims workflows, appeals processes, and reimbursement procedures aligned with CMS and state regulations.
Patient Coordinator (Concurrent Evening Shift)
TeamHealth / Access Nurse
Houston, TX
07.2023 - 07.2024
- Identified workflow inefficiencies and recommended documentation updates to improve accuracy and billing compliance.
- Applied claims research and claims adjudication support to resolve data inconsistencies across multiple systems.
- Maintained HIPAA compliance in patient records, claims documentation, and communications throughout the shift.
Senior Scheduler / Trainer
Houston Methodist Hospital
Houston, TX
02.2019 - 10.2022
- Coordinated clinical and billing workflows in Epic Cadence, Prelude, and Grand Central to support scheduling and revenue cycle operations.
- Trained new employees on Epic workflows, scheduling procedures, and documentation standards.
- Supported insurance verification, authorizations, and claims-related workflow tasks to keep scheduling and billing processes moving.
- Documented process updates, tested system configuration changes, and contributed to workflow improvements across scheduling operations.
- Reviewed scheduling and billing workflows for discrepancies that affected claims accuracy, data integrity, and revenue cycle performance.
Epic Healthcare Service Representative III
Kelsey-Seybold Clinic
Houston, TX
06.2015 - 02.2019
- Audited patient demographics, insurance information, and registration records to support billing accuracy and HIPAA compliance.
- Collaborated with IT and compliance teams to troubleshoot Epic issues affecting claims submission and reimbursement processes.
- Validated workflows, documented requirements, and tested Epic enhancements to support system changes.
- Supported MyChart, scheduling, registration, and patient access operations across daily service requests.
- Maintained compliance with HIPAA and healthcare regulatory requirements across registration and support activities.
Epic Ambulatory Application Support Specialist (Consultant) (Concurrent Evening Shift)
St. Luke's Hospital Network / HCI Group
Houston, TX
01.2018 - 03.2018
- Validated requirements and UAT scenarios for Epic workflow changes across clinical and operational teams.
- Authored user guides and training materials to support Epic adoption and workflow standardization.
- Troubleshot clinician and operational issues, translating incidents into clear fixes and follow-up actions.
- Supported process optimization efforts by reviewing workflows and identifying improvement opportunities during stabilization.
- Collaborated with ambulatory and revenue cycle teams to keep support, documentation, and workflow improvements aligned across evening shifts.
Education
Bachelor of Science - Information Technology
University of Phoenix
Phoenix, AZ07.2027
Associate of Applied Science - Medical Billing & Coding
Fortis College
Pensacola, Florida03.2013
Skills
- Claims research
- Root cause analysis
- Workflow documentation
- Requirements validation
- User acceptance testing
- Claims adjudication
- Payment integrity
- Claims remediation & reprocessing
- Revenue cycle management
- Epic workflow support
- Claims adjudication
- Claims processing
- Denial management
- EOB interpretation
- Payment integrity review
- Denial analysis
- HIPAA compliance
- Benefit verification
- Claims resolution
- Healthcare compliance
Personal Information
Title: SENIOR CLAIMS ANALYST | MEDICAID & MEDICARE CLAIMS RESEARCH SPECIALIST
Certification
HIPAA Certification
Timeline
PMO Analyst (Special Assignment)
Gainwell Technologies
03.2025 - 09.2025
Senior Test Engineer / Technical Trainer
Gainwell Technologies
02.2024 - 11.2025
Patient Coordinator (Concurrent Evening Shift)
TeamHealth / Access Nurse
07.2023 - 07.2024
Senior Provider Service Advocate / Subject Matter Expert (SME)
UnitedHealthcare Group
10.2022 - 02.2024
Senior Scheduler / Trainer
Houston Methodist Hospital
02.2019 - 10.2022
Epic Ambulatory Application Support Specialist (Consultant) (Concurrent Evening Shift)
St. Luke's Hospital Network / HCI Group
01.2018 - 03.2018
Epic Healthcare Service Representative III
Kelsey-Seybold Clinic
06.2015 - 02.2019
Bachelor of Science - Information Technology
University of Phoenix
Associate of Applied Science - Medical Billing & Coding
Fortis College