La Qoia Walker
Locust Grove
Summary
Senior-level medical claims professional with 11+ years of experience reviewing, adjudicating, and reworking complex medical claims across commercial, Medicare, Medicaid, Marketplace, and self-funded plans. Proven subject matter expert with advanced knowledge of medical necessity guidelines, eligibility verification, pre-authorization, appeals, reconsiderations, cost containment, and compliance requirements. Highly productive in fast-paced production environments with consistent achievement of quality and accuracy standards.
Overview
11
11
years of professional experience
Work History
Claims Analyst
Elevance Health
10.2024 - Current
- Apply medical necessity criteria, verify eligibility, and determine coverage to support accurate and compliant claim outcomes.
- Review and adjudicate complex medical claims exceeding standard processing authority in accordance with plan guidelines and regulatory requirements.
- Correct claim overpayments, underpayments, and processing discrepancies through rework, recalculations, and adjustments.
- Identify discrepancies and root causes by analyzing EOBs, COBs, and claim history.
- Ensure compliance with internal policies, state and federal regulations, and audit standards.
- Maintain detailed, defensible claim documentation to support audits, appeals, and reconsiderations.
- Respond to complex claim inquiries and mentor team members as a subject matter expert.
- Meet or exceed productivity, accuracy, and quality benchmarks in a remote production environment.
Claims Examiner
CoverMyMeds (McKesson)
04.2016 - 05.2024
- Processed and adjudicated high-volume medical claims across multiple plan types while consistently meeting productivity targets.
- Investigated denied, pended, and disputed claims to determine root cause and implement effective resolutions.
- Managed appeals and reconsiderations by gathering documentation, validating eligibility, and communicating determinations.
- Identified trends in overpayments, underpayments, and operational errors, escalating findings to leadership for strategic decision-making.
- Maintained compliant claim documentation to ensure audit readiness and regulatory adherence.
- Responded to phone and written inquiries from internal teams and external stakeholders regarding claim status and outcomes.
- Trained junior staff on best practices while resolving complex claim issues to enhance team capabilities.
Medical Collector
Parallon (HCA Healthcare)
Norcross
04.2015 - 04.2016
- Resolved outstanding medical claims promptly, maintaining accurate financial documentation to support revenue cycle integrity.
- Verified claim outcomes, ensuring accurate payment posting and follow-up to facilitate timely reimbursements.
- Communicated with patients and insurance carriers about claim status and resolutions, enhancing clarity and understanding.
- Researched billing discrepancies using EOBs, payer contracts, and insurance guidelines.
Education
High School Diploma -
University of Alaska Anchorage (UAA)
Anchorage, AKSkills
- Claims adjudication
- Eligibility verification
- Medical necessity
- Pre-authorization requests
- Appeals & Reconsiderations
- Claims rework
- Payment identification
- Cost containment
- Regulatory compliance
- Claims documentation
- High-volume production
- Microsoft Excel
- Salesforce
- Training and mentorship
- Customer inquiries
Timeline
Claims Analyst
Elevance Health
10.2024 - Current
Claims Examiner
CoverMyMeds (McKesson)
04.2016 - 05.2024
Medical Collector
Parallon (HCA Healthcare)
04.2015 - 04.2016
High School Diploma -
University of Alaska Anchorage (UAA)