Telisa Carter
St Louis
Summary
Organized and dependable candidate successful at
managing multiple priorities with a positive attitude.
Willingness to take on added responsibilities to meet team
goals. Resourceful Specialist offering expertise in problem-solving, data analysis and customer service. Adept at quickly learning new technologies and processes for driving success. Proven track record of successfully managing multiple projects and developing innovative solutions.
Overview
10
10
years of professional experience
Work History
Business Analyst II
Centene
11.2024 - Current
- Maintained accurate records of claim reviews, investigations, and findings, and prepare reports for internal and external stakeholders.
- Conducted comprehensive analysis across various lines of business reviewing claims before they were paid, focusing on identifying potential issues like fraud, waste, and abuse.
- Ensured claims are accurate, complete, and comply with company policies, procedures, and regulatory requirements. Determined if claims are eligible for payment based on policy terms and coverage.
- Reported findings and recommendations to management and relevant teams.
Escalations Response Specialist III
Centene
04.2021 - 11.2024
- Investigate and resolve Provider and Member complaints reported to CMS through the Complaints Tracking Module (CTM) in the Health Plan Management System (HPMS), achieving 20% reduction in escalated complaints from an in-network provider within the first year
of hire. - Contributed to a 20% reduction in claims-related escalations by collaborating with the claims department to accurately price pended claims.
- Facilitated cross-functional collaboration, leading to a 30% reduction in the resolution time for claims issues and improved accuracy in claims adjudication.
- Contributed to the implementation of three system changes, resulting in a 25% improvement in operational efficiency and timely complaint processing.
- Achieved a 98% accuracy rate in the documentation, tracking, and resolution of claims-related complaints, while concurrently overseeing internal data cleanup projects, ensuring streamlined project management.
- Maintained a 95% resolution rate in responding to providers' claims inquiries, enhancing customer satisfaction and reducing complaints turnaround time.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- · Analyzed trends in claims processing issues, contributing to a 15% improvement in overall claims efficiency.
Appeals and Grievances Coordinator
Centene
01.2020 - 04.2021
- Analyzed and adjudicated claim appeals, ensuring accurate processing in compliance with plan guidelines and prepared complex cases for medical review when required.
- Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases.
- Identifies claim issues related to authorizations that impact the resolution of the appeal.
- Reviewed claim grievance for reconsideration and either approve/deny based on determination level or prepare for medical review presentation. Prepare cases for medical review as necessary.
Insurance and Revenue Manager
Hearing Pro
03.2018 - 02.2019
- Worked within core team to streamline business processes and internal controls, resulting in scalable and detailed set of procedures.
- Hired, trained and managed revenue department team members and developed engaged, high-functioning performers.
- Reviewed customer contracts and purchase orders for revenue recognition and verified compliance with company policies and standards.
- Identified issues regarding delayed or incomplete payments and followed through to resolution.
- Established and checked coding procedures, monitored reports and updated internal files.
- Obtained data such as patient, insurance ID, insurance
- Referenced monthly aging reports to follow up on unpaid
- Calculated adjustments, premiums, and refunds
Senior Reimbursement Specialist
Express Scripts
07.2016 - 08.2017
- Managed and responded to all correspondence and
inquiries from customers and vendors - Applied mathematical abilities on daily basis to calculate
and check figures in all areas of accounting systems - Made contact with insurance carriers to discuss policies
and individual patient benefits - Verified all patient demographic information when
registering for services - Established contact with ordering physician's office to
resolve any issues or to collect missing vital information
Patient Financial Counselor
McCallum Place
04.2015 - 04.2016
- Explained insurance benefits to patients at office,
including fees and procedures - Negotiated Single Case Agreement for non contracted
Insurance Companies - Discussed financial and insurance options with patients
- Screened patients with financial needs to determine
assistance choices - Obtained patient's insurance information and determined
eligibility for benefits for specific services rendered - Identified insurance payment sources and listed payers in
proper sequence to establish chain of payment - Received patient deductibles and co-pay amounts and
discussed options to satisfy remainder of patient
financial obligations - Determined patient financial needs and referred eligible
patients to proper county, state or federal agencies to
obtain financial assistance
Education
No Degree - Medical Coding
AAPC
08.2023
No Degree - Medical Billing And Coding
Midwest Technical Institute
03.2010
No Degree - Associate Applied Science
Richland Community College
08.1992
Skills
- Skilled in Microsoft Office tools
- Accurate coding of diagnoses
- Medical terminology expertise
- Comprehensive diagnostic skills
- Understanding of HIPAA regulations
- Medical coding expertise
- Document analysis
- Benefits analysis
- Data analysis in Excel
- Medicare regulations adherence
- CMS best practices
- Investigation escalation coordination
- Experience in insurance operations
Timeline
Business Analyst II
Centene
11.2024 - Current
Escalations Response Specialist III
Centene
04.2021 - 11.2024
Appeals and Grievances Coordinator
Centene
01.2020 - 04.2021
Insurance and Revenue Manager
Hearing Pro
03.2018 - 02.2019
Senior Reimbursement Specialist
Express Scripts
07.2016 - 08.2017
Patient Financial Counselor
McCallum Place
04.2015 - 04.2016
No Degree - Medical Billing And Coding
Midwest Technical Institute
No Degree - Associate Applied Science
Richland Community College
No Degree - Medical Coding
AAPC
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