YOSMINE GASTON
Thomasville,NC
Summary
Compassionate and detail-oriented Licensed Practical Nurse (LPN) with a solid foundation in clinical nursing care, patient education, and interdisciplinary collaboration. Bringing 11 years of healthcare administration experience, including claims examination and utilization management, providing a deep understanding of insurance processes, medical terminology, and patient advocacy. Skilled in documentation, care coordination, and delivering empathetic, patient-centered support in demanding environments.
Overview
13
13
years of professional experience
Work History
LPN
Pennybyrn
03.2025 - Current
- Provide compassionate, patient-centered nursing care to long-term care residents.
- Assess residents physical and mental health and report changes in condition to providers and the interdisciplinary care team.
- Administer medications, treatments, and injections safely and accurately according to physician orders.
- Monitor vital signs, pain levels, and overall health status while identifying changes that require intervention.
- Perform wound care, dressing changes, catheter care, and other skilled nursing procedures.
- Collaborate with physicians, therapists, social workers, and other healthcare professionals to coordinate resident care.
- Educate residents and their families on medications, treatment plans, and disease management.
- Respond promptly to medical emergencies and changes in resident condition.
- Supervise and support nursing assistants to ensure high-quality resident care.
- Adhere to infection prevention protocols, HIPAA regulations, and state and federal long-term care standards.
- Assist with resident admissions, discharges, and care plan updates.
CLAIM FOLLOW UP SPECIALIST
Atrium Health
02.2025 - 06.2026
- Conducted timely follow up on medical claims with insurance carriers to resolve denials, delays, and underpayments.
- Reviewed claim statuses, payment explanations, and patient accounts to identify discrepancies and initiate corrections or appeals as needed.
- Collaborated with internal departments and payers to obtain missing information, maintain compliance with billing guidelines, and reduce claim aging.
- Remote
- Coordinated follow-up communications to ensure timely patient engagement and satisfaction.
- Collaborated with healthcare providers to resolve billing discrepancies and ensure timely reimbursements.
- Collaborated with internal teams to resolve claim discrepancies and enhance revenue cycle management.
- Developed strategies for appealing denied claims, resulting in increased approval rates.
- Monitored key performance indicators related to claim denials, driving continuous improvement efforts.
- Identified root cause of denials to provide plans for denial resolution.
- Inpatient/Outpatient
- Eob/Eop
- Documented medical claim actions by completing forms, reports, logs and records.
- Verification of benefits.
CLINICAL SUPPORT SPECIALIST
Capital Blue Cross
09.2023 - 11.2024
- Supported the Clinical Management Department by coordinating patient service requests and processing referrals.
- Verified eligibility, benefits, and prior authorizations while maintaining excellent communication with members and providers.
- Functioned as a liaison between patients, providers, and internal nursing staff to ensure timely care coordination.
- Remote
- Facilitated communication between departments to enhance interdisciplinary collaboration in patient care.
- Communicated medical need for patient visits to scheduling department.
- Streamlined internal processes for better coordination between medical staff and patients, leading to increased quality of care.
- Served as a reliable resource to both healthcare providers and patients alike, addressing questions or concerns promptly and knowledgeably.
CLAIMS EXAMINER
Versant Health
10.2022 - 03.2024
- Reviewed vision claim submissions and ensured compliance with healthcare regulations.
- Applied critical thinking to resolve discrepancies and improve claims accuracy.
- Remote
- Collaborated with insurance providers to resolve billing discrepancies and expedite payments.
- Reduced claim denials by thoroughly reviewing medical documentation and ensuring accurate coding practices.
- Maintained strict adherence to HIPAA guidelines and regulations, ensuring the confidentiality and security of all patient information.
- Posted payments and collections on regular basis.
- Delivered timely and accurate charge submissions.
- Analyzed clinical documentation for accurate coding in compliance with industry standards.
- Demonstrated expertise in various code sets including CPT, HCPCS Level II, ICD-10-CM/PCS codes.
UTILIZATION MANAGEMENT REPRESENTATIVE
Anthem
04.2021 - 10.2022
- Collaborated closely with nurse reviewers to support behavioral health clinical authorization decisions.
- Determined contract and benefit eligibility for inpatient and outpatient procedures.
- Strengthened knowledge of managed care principles and clinical review criteria.
- Evaluated medical necessity and appropriateness of services for member care plans.
- Inpatient/Outpatient (Substance-abuse/Mental health)
- Facilitated prior authorization requests by analyzing patient information and insurance policies.
- Analyzed medical records and other documents to determine approval of requests for authorization.
- Verified eligibility and compliance with authorization requirements for service providers.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Reduced turnaround time for prior authorization requests by utilizing electronic submission methods.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
CLAIMS EXAMINER
Aetna
High Point, NC
10.2017 - 10.2020
- Processed Medicare and Medicaid claims with attention to accuracy and compliance.
- Monitored CPT, ICD-9, and HCPCS coding for correctness and coordinated benefits with other insurers.
- Analyzed claims to determine validity and compliance with policy guidelines.
- Conducted audits of claims to ensure adherence to regulatory requirements.
- Resolved complex claims disputes through effective communication and negotiation skills.
- Participated in cross-functional team meetings to address organizational challenges related to claims management and develop solutions collaboratively.
- Researched claims and incident information to deliver solutions and resolve problems.
MEDICAL BILLING SPECIALIST / CUSTOMER SERVICE REP
Management Consultants
Winston-Salem, NC
02.2016 - 10.2017
- Managed patient billing and claim follow-ups while supporting positive client relationships.
- Resolved patient inquiries, ensuring accuracy and empathy in communication.
- Coordinated with healthcare providers to obtain necessary documentation for claim submissions.
- Posted and adjusted payments from insurance companies.
- Verification of benefits.
- Identified and resolved patient billing and payment issues.
- Assisted patients with understanding their medical bills and provided clarification on complex insurance issues, promoting a positive customer experience.
- Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
- Analyzed complex Explanation of Benefits forms to verify correct billing of insurance carriers.
CUSTOMER SERVICE REPRESENTATIVE
UnitedHealthcare Group
Greensboro, NC
01.2013 - 11.2015
- Assisted members with benefits, claims, and healthcare coverage questions.
- Demonstrated exceptional communication and critical thinking skills in high-volume settings.
Education
Practical Nursing Diploma - undefined
ECPI University
12.2025
Skills
- Empathetic and patient-focused approach to care
- Commitment to continuous learning and professional growth
- Medication Administration
- Electronic Health Records (EHR/EMR)
- Insurance & Authorization Processes
- Microsoft Software
- Preventive care
- Diagnosis and treatment
- Excellent multitasking and time management skills
- Patient Care & Safety
- Wound Care & Vital Signs
- Care Coordination & Communication
- HIPAA & Compliance Standards
- Proficient in Epic, Facets, Aumi, Efax, Salesforce, Collaborate MD, and Guiding Care/Health Edge systems
- Patient education
Timeline
LPN
Pennybyrn
03.2025 - Current
CLAIM FOLLOW UP SPECIALIST
Atrium Health
02.2025 - 06.2026
CLINICAL SUPPORT SPECIALIST
Capital Blue Cross
09.2023 - 11.2024
CLAIMS EXAMINER
Versant Health
10.2022 - 03.2024
UTILIZATION MANAGEMENT REPRESENTATIVE
Anthem
04.2021 - 10.2022
CLAIMS EXAMINER
Aetna
10.2017 - 10.2020
MEDICAL BILLING SPECIALIST / CUSTOMER SERVICE REP
Management Consultants
02.2016 - 10.2017
CUSTOMER SERVICE REPRESENTATIVE
UnitedHealthcare Group
01.2013 - 11.2015
Practical Nursing Diploma - undefined
ECPI University