Laquinta Grissom
Durham
Summary
Medical Claims Analyst skilled in analyzing complex claims and ensuring accurate payment determinations. Expertise in applying medical necessity guidelines and verifying eligibility while maintaining compliance with regulatory standards. Known for exceptional accuracy in high-volume environments, contributing to efficient reimbursement and claims resolution.
Overview
10
10
years of professional experience
Work History
Medical Claims Analyst
Confidential Health Insurance Payor
Durham
11.2022 - Current
- Analyze complex medical claims beyond standard adjudication authority to ensure accurate processing and payment determination.
- Apply payer policies, clinical guidelines, and medical necessity criteria to validate coverage and eligibility.
- Investigated claim discrepancies, identifying overpayments, underpayments, and processing errors to ensure accurate claims resolution.
- Performed claims rework calculations and adjustments to correct inaccuracies, facilitating timely reconsideration requests.
- Communicated with providers and members to gather documentation and resolve claim disputes, enhancing claims processing efficiency.
- Ensure all claim decisions align with regulatory requirements, reimbursement standards, and company policy.
- Maintain productivity and accuracy targets in a high-volume claims review environment.
- Provide technical guidance and training to team members to improve claims processing accuracy.
Revenue Cycle Financial Representative
UNC Health Care
Durham
02.2019 - 11.2022
- Managed hospital and physician billing inquiries via inbound calls, online patient portals, and written communication, enhancing patient understanding of their accounts.
- Handled hospital and physician billing inquiries through inbound calls, online patient portals, and written communication.
- Processed charge reviews, payment plans, refunds, and claim corrections, facilitating timely and accurate account resolution.
- Collaborated with Patient Relations and Risk Management teams to resolve escalated billing issues.
- Reviewed claims for compliance with medical necessity requirements and insurance policies.
- Identified overpayments or underpayments and completed claims adjustments.
- Maintained precise financial documentation, supporting proper reimbursement and adherence to regulatory compliance.
Collector
Professional Recovery Consultant
04.2017 - 01.2019
- Negotiated payment arrangements with patients, successfully resolving outstanding balances and minimizing delinquent accounts.
- Ensured compliance with federal and organizational regulations throughout collection activities.
- Maintained compliance with federal and organizational regulations during all collection activities.
- Supported supervisors in managing complex or escalated accounts through advanced negotiation techniques.
- Assisted supervisors with complex or escalated accounts requiring advanced negotiation.
Customer Care Representative
Xerox / Conduent
10.2016 - 04.2017
- Resolved customer service inquiries through effective use of multiple internal systems and databases, enhancing customer satisfaction.
- Resolved customer service inquiries using multiple internal systems and databases.
- Educated customers on insurance plan options, coverage details, and service procedures.
- Documented interactions to ensure accurate case resolution and timely follow-up, contributing to improved service reliability.
Education
General Studies - Medical Office Assistant
Southern High School
Durham, NC01-2016
Medical Office Administration -
Center For Employment Training
DurhamSkills
- Claims processing
- Coverage determination
- Eligibility verification
- Claims adjustment
- Claims production
- Payment analysis
- Regulatory compliance
- Epic Electronic Health Record (EHR)
- Revenue Cycle Operations
- Financial analysis
- Microsoft Excel
- Microsoft Office Applications
- Microsoft Word
- Provider and Member Communication
Affiliations
- Professional Development & Activities
Excel & Data Analysis Skill Development
Continuously improve Excel skills through hands-on use in daily work, including data tracking, reporting, and trend analysis
Process Improvement Contributions
Actively identify workflow inefficiencies and share recommendations with team members to improve accuracy and efficiency
Peer Support & Training Assistance
Provided informal guidance to new team members on systems, processes, and best practices to support team productivity
High-Volume Operations Experience
Developed strong time management and multitasking skills while working in fast-paced, deadline-driven environments
Timeline
Medical Claims Analyst
Confidential Health Insurance Payor
11.2022 - Current
Revenue Cycle Financial Representative
UNC Health Care
02.2019 - 11.2022
Collector
Professional Recovery Consultant
04.2017 - 01.2019
Customer Care Representative
Xerox / Conduent
10.2016 - 04.2017
General Studies - Medical Office Assistant
Southern High School
Medical Office Administration -
Center For Employment Training