Melissa Loy
Nixa
Summary
Hardworking career in medical claims bringing over 25 years of experience. Excellent oral and written communication, organizational and problem-solving skills. Looking to apply knowledge and abilities to challenging new role.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Reconsideration Specialist
CareCentrix
Springfield
03.2023 - Current
- Reviews denied medical claims and process reconsiderations with insurance payers to ensure proper reimbursement for providers. Key responsibilities include analyzing denial reasons, gathering supporting documentation, drafting compelling letters based on clinical and payer guidelines, and tracking the status of reconsiderations to final resolution. Liaison with healthcare providers and payors, communicate with supervisors about issues, and maintain compliance with regulatory protocols and organizational policies.
Denials Specialist
Ensemble Health Partners
Richmond
04.2022 - 01.2023
- Corrected/resubmitted denied payments by insurance & submitting appeals in a timely manner. Negotiated out of network claims. Knowledge of Fair Health & No Surprise claims, MNRP, MCRII, WC & Anesthesia claims.
Revenue Cycle Sr Consultant
Revenue Cycle Consultant
Springfield
08.2017 - 04.2022
- Experience with Zirmed, Cerner, Esolutions, PC-Ace, Matrixcare, DDE, Availity & Netsmart Billed hospice & home healthcare claims for multiple clients Posted remits from insurance carriers for multiple clients on a variety of software Followed up on incorrectly paid claims with multiple insurance carriers
HC & Insurance Ops Claims Manager
Dell Inc
Nixa
10.2012 - 06.2017
- Experienced in Xcelys/Facets/Macess/Qcare, Webstrat, CAI software Processed MROA Medicare claims & authorizations distributed workflow in team Adjusted/reversed members claims history processed incorrectly
Savings Investigation Analyst
COX HEALTH PLANS
Springfield
08.2006 - 09.2012
- Reviewed pre-existing conditions, updated provider contracts & med docs Repriced out of network claims thru PCHS, Concentra & Multiplan Processed work comp and 3rd Party Liability, COB claims
Claims Adjustment Examiner
GREAT WEST INC
Ft Scott
01.2000 - 08.2006
- Applied appropriate CPT4/HCPS/ICD9 & ICD 10 coding Researched pre-existing conditions Processed claims MCR/Medicaid/TPL/COB/Work Comp and No Fault guidelines
Education
Bachelor of Science Human Resources -
PITTSBURG STATE UNIVERSITY
Pittsburg, KS01.1998
Certification
HFMA Certified Revenue Cycle Representative, 01/2023
Timeline
Reconsideration Specialist
CareCentrix
03.2023 - Current
Denials Specialist
Ensemble Health Partners
04.2022 - 01.2023
Revenue Cycle Sr Consultant
Revenue Cycle Consultant
08.2017 - 04.2022
HC & Insurance Ops Claims Manager
Dell Inc
10.2012 - 06.2017
Savings Investigation Analyst
COX HEALTH PLANS
08.2006 - 09.2012
Claims Adjustment Examiner
GREAT WEST INC
01.2000 - 08.2006
Bachelor of Science Human Resources -
PITTSBURG STATE UNIVERSITY
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