Aquonya Cason Vaughn
Monticello
Summary
Dynamic Senior Lead Grievance & Appeal Analyst at Elevance Health, specializing in Medicaid policy alongside appeals and grievances. Established history of enhancing operational efficiency and crafting impactful performance reports. Proficient in problem-solving and effective communication, facilitating policy improvements and promoting collaboration across teams. Dedicated to achieving high-quality results within healthcare sector.
Overview
27
27
years of professional experience
Work History
Senior Lead Grievance & Appeal Analyst
Elevance Health
Atlanta
04.2010 - Current
- Analyzed healthcare data to identify trends supporting informed decision-making.
- Collaborated with teams to enhance operational efficiency in community health programs.
- Developed performance reports for stakeholder review and strategic planning.
- Conducted research to support policy development and improve service delivery models.
- Provided Medicaid policy training to junior analysts and staff members.
- Maintained positive relationships with staff and management to foster collaboration.
- Identified customer needs promptly, proposing effective solutions for efficiency and cost issues.
- Documented adverse determinations and appeals, ensuring compliance with NCQA standards.
Cost Containment Unit /Overpayment Recovery Specialist
Amerigroup Community Care
Tampa
06.2006 - 04.2010
- Responsible for identifying the root cause of overpayment issues, while focusing on the company’s annual savings.
- Responsible for analyzing and investigating overpayments due to system inaccuracies, incorrect processing, Ability to interpret provider Medicaid contracts.
- Handled all provider appeals for the Tampa Cost Containment Unit, including those sent from the Florida Health Plan, regarding Overpayment Recovery projects.
- Ensured correct coordination of Commercial, Medicare, and Auto Insurance carriers due to Medicaid’s standards.
- Resolved correspondence by researching provider and member information, regarding contract overpayment and Third Party Liability issues.
- Assisted in training and, developed training material for new hire CCU Overpayment Processors and Specialists.
- Ensured that all issues were researched, documented and processed within a timely manner.
Appeals and Grievance Coordinator
UnitedHealthcare
Oldsmar
11.2003 - 06.2006
- Review and triage correspondence related to appeals and grievances.
- Research issues to determine appropriate action write/originate letters.
- Ensure policies and procedures are properly met.
- Contact members and providers to obtain needed information.
- Log appeals and grievances in the system and maintain files.
- Meet all compliance and regulatory time frames.
- Master appeals and grievance regulations.
Claims Examiner
Cadent Administrators
St. Petersburg
11.2001 - 05.2003
- Process medical claims for the Texas CHIP kids programs.
- Request information based on policy provisions from the insured and provider.
- Interaction with Customer Service to insure policyholder and provider satisfaction.
- Maintain company quality standards of 95% Statistical Accuracy and 99% Payment Accuracy.
Sr. Claims Examiner
Wakely and Associates
Clearwater
02.1999 - 10.2001
- Processed claims for Medicare, Team Lead, responsible for training new employees on policies and procedures, also workload distribution.
Education
Bachelor’s Degree - Healthcare Administration
University of Phoenix
12.2014
Skills
- PC proficiency and Microsoft Office Suite
- Production standards achievement
- Subject matter expertise in appeals and grievances
- Healthcare industry experience
- Effective communication skills
- Education delivery to diverse populations
- Claims processing and healthcare regulations
- Performance reporting and analysis
- Training development and delivery
- Problem solving and critical thinking
- Attention to detail and decision making
- Team collaboration and leadership
- Time management and deadline adherence
- Policy improvements and writing
- State Fair Hearing
- Research and analysis
Timeline
Senior Lead Grievance & Appeal Analyst
Elevance Health
04.2010 - Current
Cost Containment Unit /Overpayment Recovery Specialist
Amerigroup Community Care
06.2006 - 04.2010
Appeals and Grievance Coordinator
UnitedHealthcare
11.2003 - 06.2006
Claims Examiner
Cadent Administrators
11.2001 - 05.2003
Sr. Claims Examiner
Wakely and Associates
02.1999 - 10.2001
Bachelor’s Degree - Healthcare Administration
University of Phoenix