QuiTiffney Grier
Columbus
Summary
Experienced Auditor focused on improving business compliance, workflow and processes through detailed audits and optimization recommendations. Successful track record of fully evaluating information, structures and procedures and initiating corrective actions.
Overview
11
11
years of professional experience
Work History
Oversight Program Auditor Sr
Elevance
10.2021 - Current
- Identifies processing, system and/or operational issues to ensure claims are paid according to provider contracts and CMS guidelines and current ICD-10/CPT coding.
- Preform WGS claim audits for Subsidiary Groups associates.
- Provide feedback on any identified errors.
- Participates in calibration calls with Delegates/Subsidiary Groups to analyzes audit results and identify ways for potential improvements to processes and procedures and/or questions that arise over the audit findings.
- Train and support staff on WGS, Solutions Central, BlueSquared and WCF.
- Monitor compliance with laws, regulations, and policies for all LOBs.
- Planned and executed follow-up audits at appropriate intervals.
Performance Quality Analyst I-II
11.2018 - 10.2021
- Successfully facilitated New Hire Presentation with all NH classes.
- Met with a committee to establish the training curriculum that the QA trainer would demonstrate.
- Attended 4 hours of observation and completed the observation feedback to ensure our deliverables covered HIPAA, call coaching, FCR, and TCPA.
- Created a FCR resource guide and trained associates on the FCR and provided material necessary for this to be a success.
- Work with Management and Learning and development team to keep them engaged on the status and progression of the FCR training.
- Perform quality audits of the work completed by the mentees.
- Provide operation training, assist associates by answering day to day technical questions and education on One Day Grievances.
- Side by side live monitoring for all LOBs.
- Providing written feedback sharing examples to the associate along with their SCORE card..
- Review and modify existing policies and/or desktop procedures.
- Scheduled call coaching through Genesys.
- Trained and supported leadership on requesting manager access in SCORE.
- Created a step-by-step documentation used for Facets to include how to log in, access your member, verify COB information, locate the members prefix ETC.
- Attend monthly calibration calls with leadership to analyzes audit results and identify ways for potential improvements to processes and procedures.
- Conducts claims audits to ensure proper billing practices from contracted and non-contracted providers by reviewing reimbursement policies, medical policies, pricing, member benefits and provider contracts.
- Platforms used WGS, Solution Central, NASCO, CS90, Facets, and WCF.
Outreach Care Specialist
03.2018 - 11.2018
- Conducted telephonic outreach to members for appointment scheduling, social determinant of health needs assessment, and care gap closure.
- Collaborated with social workers and care managers to develop action plan for members.
- Created a step-by-step document used for sending letters in Macess.
- Documented interactions in electronic medical records and completed all other required documentation in a timely manner.
- Lead and facilitate meetings.
Network Data Spec
01.2017 - 03.2018
- Managed daily workflow in provider demographic systems EPDS, R6, and ePACT.
- Analyzed reports identify and document system problems, gaps, or inconsistencies in workflows, and processes; recommend updates, alternatives and or solutions.
- Assists in auditing provider database to ensure provider data is termed or updated correctly in EPS.
- Attended meetings with the credentialing team address critical issues with improper loading of provider contracts.
Customer Services Rep III
AHG
09.2015 - 01.2017
- Assisted members daily with COB, resolving claim inquiries, benefit, and enrollment issues while making a connection during the contact.
- Served as a first line resource for day-to-day CCB/Solution Central claim processing questions.
- Research and resolves claim on CCB/Solution Central for all claim types.
- Performed peer to peer auditing and assisted with the development of skill.
- Assisted in increasing member's engagement into appropriate programs and offerings for AHG.
- Work with internal staff from other departments to ensure customer satisfaction.
Customer Services Rep I-II
ITS Host
10.2013 - 09.2015
- Provided claim status using QCARE, NASCO, and Blue2 on a day-to-day basis.
- Researched pricing using Networx pricer, McKesson and Claims Xten to resolve provider billing inquiries.
- Reduced inventory for aged high-profile accounts for claims, adjustment, and inquiry tracking.
- Utilizes guidelines and medical review to analyze and route claims/medical records for staff review via BlueSquared.
Education
Bachelor of Science - Health Administration
University of Phoenix
Tempe, AZ01.2017
Medical Billing and Coding Specialist
CENTURA COLLEGE
Charleston, SC01.2010
Skills
- Policy evaluation
- Process evaluations
- Financial records review
- Balance sheets
- Audit reporting
- Compliance standards
Timeline
Oversight Program Auditor Sr
Elevance
10.2021 - Current
Performance Quality Analyst I-II
11.2018 - 10.2021
Outreach Care Specialist
03.2018 - 11.2018
Network Data Spec
01.2017 - 03.2018
Customer Services Rep III
AHG
09.2015 - 01.2017
Customer Services Rep I-II
ITS Host
10.2013 - 09.2015
Bachelor of Science - Health Administration
University of Phoenix
Medical Billing and Coding Specialist
CENTURA COLLEGE
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