Tanithia Norris
Calumet City,IL
Summary
With over 10 years of experience in the health insurance and managed care industry, I bring extensive knowledge in claims adjudication and auditing. Expertise lies in ensuring compliance and accurate payment of claims using SAS Reports. Responsible for adjudicating various types of claims, including Medicare, Medicaid, inpatient, outpatient, dialysis, skilled nursing, behavioral health, and long-term care services. Conducted audits such as concurrent, retrospective, and employee commercial plans. Successfully facilitated the deposit of over $4 million worth of claims by creating pre-release reports for clients. Conducted Audit the Auditor claim audits to ensure procedural, financial, and operational accuracy. Healthcare professional with extensive experience in medical claims processing and resolution, consistently demonstrating efficiency in handling claims and resolving discrepancies while maintaining compliance. Strong team collaboration skills, adaptability, and commitment to achieving results recognized throughout career.
Overview
13
13
years of professional experience
Work History
Medical Claims Specialist | Medical Claim Processor
Access Community Health Network
11.2020 - Current
- Developed SOPs detailing the processing of several claims and rendered services.
- Maintain superior accuracy in adjudicating numerous claims each day.
- Handled provider and member communications efficiently.
- Collaborated with Health Plan to address changes in policy and procedures for Medical IPA Group.
- Ensured accurate medical group authorizations for services on weekly Work 095 report from health plan.
- Assure claims are stamped GA (group approved) and NGA (non-group approved) to assure accurate claim processing from health plan claims department
- Reduced errors in claims submissions through meticulous attention to detail and thorough review processes.
- Improved claim processing efficiency by streamlining workflows and implementing best practices.
- Submitted electronic/paper claims documentation for timely filing.
- Examined and resolved complicated insurance claim discrepancies ensuring timely handling.
- Paid or denied medical claims based upon established claims processing criteria.
INTERNAL AUDITOR-CONTRACT
Healthcare Service Corporation
12.2019 - 03.2020
- Conducted audits of financial and operational controls of various departments via Teammate
- Ensured compliance with prescribed procedures and policies
- Provided independent assurance that organization’s risk management, governance and internal control processes were operating effectively
- Evaluated and reported to highest level in organization of all findings or minor issues
- Audited controls to test effectiveness of control used by client entity to prevent and detect any misstatements
- Created Walkthrough narratives to assess overall risks of material misstatement to financial statement
QUALITY ASSURANCE AUDITOR
EVOLENT HEALTH LLC
06.2018 - 07.2019
- Ensured claims were adjudicated in compliance with provider contract parameters, member demographic information, and service level requirements through random and targeted claims reviews
- Via Aldera
- Conducted audits for various clients to ensure compliance
- Generate SAS reports for pre-release issues through Aldera
- Responsible for auditing concurrent audits, retrospective audits, employee commercial plans and creating pre-release reports for clients to deposit worth $4 million worth of claims
- Conducted Audit to Auditor claim audits for procedural and financial accuracy
- Provided monthly/quarterly/yearly feedback used for client report cards and company Key Performance (KPI)
- Participated in documenting and prioritizing potential solutions to issues and fallout for system issues
- Established and implemented interim workaround solutions as needed and communicated to all impacted users
- Assisted in establishing, updating, and communicating new and existing policy and procedures
- Facilitated discussions and solutions with matrix partners and acted as subject matter expert
- Was Accountable for analyzing and measuring results of implemented policies, changes and system modifications
- Handled multiple and concurrent initiatives
- Effectively communicate across all levels of management and management personnel
MEDICAL CLAIMS SPECIALIST
FAMILY HEALTH NETWORK
11.2016 - 06.2018
- Responsible for Adjudicating and Auditing claims to make sure claims were paid correctly and ensured compliance
- Compared data on claim form with insurance plan to a certain completeness and validity of claim
- Proactively worked to resolve claim discrepancies as expeditiously as possible and calculated reimbursement of benefits according to schedule of coverage
- Ran various claim reports and Assisted Supervisor/Team Leader in examining duplicate, timely filing and explanation of benefits reports
- Adjudicated Medicare/Medicaid/Inpatient/Outpatient/Dialysis/Skill Nursing/Behavioral Health/Long Term Care Services and all other specialty claims
- Viewed patient registration via Invidasys
- Examined claim form and other records to determine insurance coverage
- Analyzed claims to determine eligibility, medical facts, policy coverage and limitations
- Daily process of 100-200 claims
MEDICAL CLAIMS SPECIALIST
CHICAGOLAND MEDICAL SERVICES ORGANIZATION
12.2014 - 04.2016
- Responsible for Adjudication of Medicare/Medicaid and Commercial Inpatient/Outpatient facility and professional claims via Microderm Encoder Plus and 3m
- Assisted in Auditing claims to make sure claims were paid correctly and ensuring compliance
- Created new ER/Inpatient Authorizations into Quick Cap
- Analyzed claims to determine eligibility, medical facts, policy coverage and limitations
- Viewed patient registration via Quick Cap
- Daily process of 200 claims
REGISTRATION SPECIALIST
LOYOLA UNIVERSITY MEDICAL CENTER
09.2011 - 01.2014
- Auditing responsibilities to make sure that claims are paid correctly and ensuring compliance
- Performed insurance verifications, created hospital account records (HAR'S) and corrected any errors found during audits of patient registrations and kept a daily log of productivity with a total of over 100 accounts touched daily
- Adjudicated all Inpatient and Outpatient medical claims
- Worked closely with the Physician's Group
- Obtained benefit verification and necessary authorizations (such as referral or precertification's) prior to patient arrival for all ambulatory visits, procedures, injections, and radiology services
- Reviewed Patient registrations via Epic, and assisted in the reduction of backlog claims
- Answered high volumes of incoming phone calls from patients, physicians, insurance companies and clinic staff to confirm/facilitate authorization for services rendered
Education
Bachelor of Science - Medical Office Administration
KAPLAN COLLEGE
Hammond, IN01.2008
Skills
- Coding conventions
- Anesthesia services
- ICD 10 coding
- CPT coding
- Complaint resolution
- Explanation of Benefits (EOB)
- Medical insurance procedures
- Reimbursement procedures
- Medical office administration
- Medicaid
- Medicare
- Managed Care
- HMO
- Private pay
- HIPAA
- Healthcare compliance
- Claim appeals handling
- Claim denials management
- Customer service
- EOB analysis
- Insurance claims processing
- Medical terminology
- Financial analysis
- Data security procedures
Timeline
Medical Claims Specialist | Medical Claim Processor
Access Community Health Network
11.2020 - Current
INTERNAL AUDITOR-CONTRACT
Healthcare Service Corporation
12.2019 - 03.2020
QUALITY ASSURANCE AUDITOR
EVOLENT HEALTH LLC
06.2018 - 07.2019
MEDICAL CLAIMS SPECIALIST
FAMILY HEALTH NETWORK
11.2016 - 06.2018
MEDICAL CLAIMS SPECIALIST
CHICAGOLAND MEDICAL SERVICES ORGANIZATION
12.2014 - 04.2016
REGISTRATION SPECIALIST
LOYOLA UNIVERSITY MEDICAL CENTER
09.2011 - 01.2014
Bachelor of Science - Medical Office Administration
KAPLAN COLLEGE
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