Anita Thompson Gordon
Murfreesboro
Summary
Results-driven Claims Analyst with extensive experience at Luminaire Health Benefits, adept at resolving complex claims and ensuring compliance with HIPAA regulations. Proficient in EDI and data validation, I excel in maintaining patient confidentiality while delivering high-quality outcomes. Recognized for attention to detail and effective communication skills in fast-paced environments.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Claims Analyst
Luminaire Health Benefits
Bloomfield
11.2022 - 12.2025
- Investigate, secure and analyze information pertaining to claimants' medical condition and proof of loss documents for life claims.
- Identify and resolve fact discrepancies and secure additional documentation as needed within required state and federal timeframes.
- Review and interpret policy provisions to accurately determine eligibility.
- Calculated benefit payments and communicated claim decisions on new and continuing claims, ensuring compliance with company policies.
- Manage ongoing claims to the appropriate payment duration.
- Properly document cases by updating appropriate note system, denoting all action taken on each case.
- Maintained accurate reserve liability for the company, supporting financial integrity and risk management.
- Documented all claims activities in the claims management system, enhancing case tracking and information accessibility.
- Utilized claims processing software to update and maintain accurate claim files.
Complex Authorization Specialist
TriWest HealthCare Alliance
02.2016 - 10.2020
- Review and enter complex authorizations and referrals from VA and providers.
- Ensured accurate data entry and completion of authorization data from customer information, medical records, and referral/authorization forms, while assisting Patient Service Representatives (PSRs) in timely acquisition of consult reports.
- Requests appropriate records and process initial review of those records.
- Effectively communicate medical information, test results, diagnoses and or proposed treatment in a manner easily understood by the patients.
- Take appropriate measures to comply with HIPAA regulations to protect privacy of Veteran's health information.
- Works with standard coding systems including: standard medical taxonomy, International Classification for Diseases, Current Procedural Terminology, and Health Care Common Procedure Coding System.
- Obtained and organized medical records in the medical management system for thorough quality of care review.
- Identified and addressed discrepancies in the medical management system to support quality compliance initiatives.
Denials Resolution Analyst
HCA Physician Services
09.2010 - 08.2015
- Review, identify, and resolve payer denials.
- Review denied claims and make appropriate decision for claims to be reviewed by the clinical Denials unit for the appeals process, Review and approve claims for adjustments.
- Post adjustment within my authority, forward claims to Team Lead to ensure adjustments are posted timely and correctly for denied claims that need adjusted off.
- Followed up on denied claims, coordinating with posting review for paid claims and conducting payment research in compliance with payer requirements.
- Review claims and follow up on requests for refunds or recoupment in accordance with payer requirements.
- Managed claims status updates, liaising with insurance companies, resubmitting claims for payment, processing corrected claims, updating patient demographics and insurance information, and verifying patient benefit status.
- Working special projects, No Claim on file with payer, review, process Medicare Claims, other payers claims, ERA Payer Denial Claims.
- Verify providers credentials, obtaining information for EDI Review, EDI Enrollment, Provider Enrollment Review.
- Facilitated training sessions for new employees on company procedures and policies.
Education
High School Diploma - High school diploma or GED
Stratford High School
Nashville, TNSkills
- EDI
- Data query management
- Data validation
- Data collection
- Microsoft Excel
- EClinicalWorks
- EMR Systems
- ICD-10
- ICD-9
- HCPCS
- Medical Records
- Databases
- Documentation review
- Research data analysis
- Data entry
- Microsoft Office
- Microsoft Word
- Microsoft Outlook
- Microsoft PowerPoint
- Productivity software
- Attention to detail
- Maintaining patient confidentiality
- Research
Certification
Driver's License
Timeline
Claims Analyst
Luminaire Health Benefits
11.2022 - 12.2025
Complex Authorization Specialist
TriWest HealthCare Alliance
02.2016 - 10.2020
Denials Resolution Analyst
HCA Physician Services
09.2010 - 08.2015
High School Diploma - High school diploma or GED
Stratford High School