Tara Dixon
Urbana
Summary
Experienced and dedicated healthcare professional with 21+ years in healthcare and health insurance. Proficient in healthcare processes, including claims processing, appeals process streamlining, and regulatory compliance. Skilled in identifying and implementing process improvements. Currently acquiring data analysis training to enhance technical abilities and seeking a role in supporting system application implementation, testing, modification, and administration.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Member Relations Coordinator
Health Alliance
01.2017 - Current
- Research, analyze and resolve member and provider formal appeals in accordance with plan guidelines and regulatory requirements.
- Research and analyze claim denials and prior authorization issues to identify root causes and assist in resolution.
- Review benefit plan documents (Schedule of Benefits, Summary Plan Descriptions, Policies & Procedures) to assess coverage and appeal outcomes.
- Identify trends in appeals and claim denials, recommending process improvements to enhance efficiency.
- Ensure compliance with state and federal regulations by following required timeframes and documentation standards.
- Accurately document and track all formal appeals in a specialized appeals system, ensuring correct coding, categorization and reporting.
- Assist in troubleshooting claims and prior authorization issues, making corrections when necessary.
- Performs comprehensive research related to the facts and circumstances of the appeal including obtaining additional information from internal and external entities.
- Work within multiple healthcare systems and databases to retrieve, review, and analyze case information.
- Coordinate Medical Director and Independent Review Organization (IRO) case submissions, ensuring all necessary information was included.
- Educate members and providers on appeal rights, claim denials, and prior authorization processes to improve understanding and prevent future issues.
- Provide internal support by sharing insights on appeal trends to improve operational workflows.
- Write professional decision letters to be sent to members and providers to advise of the appeal decision and rational, including the next level of appeal and future rights.
Customer Service Representative II
Health Alliance
02.2004 - 12.2016
- Responsible for accurately and completely answering and documenting inquiries from members, employers, employer groups and providers
- Facilitated communication between self, other departments, members, providers, provider offices, employers, and brokers to ensure that needs of members are met
- Assumed responsibility for documentation, answering and follow-up on all coverage and claims inquiries from Health Alliance members and providers generated by telephone, walk-in, or written correspondence
- Educated members and providers regarding a variety of insurance issues, including, but not limited to coordination of benefits and Medicare coordination, utilization of benefits outside of service area, and explanation of COBRA to members losing coverage
- Acted as a leader, example and lead resource person for the Customer Service Department, and in a supervisory role under the guidance of the Customer Service Manager
- Responsible for accurately and completely answering and documenting inquiries and escalated issues from all internal and external customers
- Facilitated communication between self, other departments, member, providers, provider offices, employers, and brokers to ensure that needs of members are met
Education
No Degree - Associate of Science
Parkland College
Champaign, ILSkills
- Claims Processing Knowledge
- Proactive Self-Starter
- Microsoft Office
- Customer service
- Workflow optimization
- Medical terminology
- Data entry proficiency
- System Documentation & Policy Interpretation
- Problem-solving capacity
- Verbal and written communication
Certification
Break Into Tech- Data Analytics Certificate Course
In Process
Timeline
Member Relations Coordinator
Health Alliance
01.2017 - Current
Customer Service Representative II
Health Alliance
02.2004 - 12.2016
No Degree - Associate of Science
Parkland College
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