Tiffany Lemke
Chicopee
Summary
Compliance-driven healthcare professional with specialized expertise in Medicare appeals, currently multi-LOB training, and complex dispute resolution. Experienced in navigating regulatory requirements with precision, contributing to CMS audit preparation, and managing cases efficiently to ensure timely, accurate outcomes. Known for building clarity in workflows, mentoring teammates based on their learning styles, and collaborating across departments to support high-quality results. Currently earning a degree in Health Administration with a focus on compliance and leadership, bringing fresh academic insight into real-world application.
Overview
8
8
years of professional experience
Work History
Appeals Specialist
WellSense Health Plan
12.2024 - Current
- Collaborated with cross-functional teams to gather necessary documentation and evidence to support the appeals process.
- Achieved successful appeal outcomes by meticulously reviewing and analyzing claim denials, identifying errors, and presenting persuasive arguments.
- Expedited resolution times for appeals cases by efficiently managing workload and prioritizing urgent matters.
- Supported CMS Data Validation audit preparation by compiling compliant documentation and validating sample accuracy across systems.
- Processed Medicare member appeals in alignment with CMS, ensuring timely and accurate case handling.
- Collaborated with team leads and clinical reviewers to ensure proper documentation and resolution of medical necessity disputes.
Resolution Specialist
WellSense Health Plan
03.2024 - 12.2024
- Analyzed root causes of recurring issues to implement preventive measures, reducing the number of future complaints.
- Handled escalated calls with professionalism, ensuring members felt heard and supported.
- Collaborated with internal departments to gather case information and ensure accurate responses.
- Managed high volumes of customer inquiries with a focus on timely and effective resolutions.
- Maintained detailed records of interactions and resolutions to enhance future case handling efficiency.
- Provided guidance and support to colleagues handling challenging situations.
- Investigated recurring issues through root cause analysis and implemented measures to reduce future complaints.
Senior Service Specialist
WellSense Health Plan
01.2023 - 03.2024
- Delivered exceptional customer experiences through proactive communication and efficient problem-solving techniques.
- Improved client retention rates by addressing concerns promptly and providing tailored solutions to meet their unique needs.
- Successfully navigated multiple projects simultaneously while adhering to strict deadlines and quality standards.
- Managed high call volume while maintaining a courteous and professional demeanor.
- Assisted new employees with training, sharing best practices for handling difficult situations and achieving positive outcomes.
- Adapted quickly to changes in company policies or procedures ensuring consistency in delivering accurate information to customers.
Personal Care Assistant
Stavros Center For Independent Living
09.2017 - 12.2022
- Assisted clients with daily living needs to maintain self-esteem and general wellness.
- Maintained detailed documentation of client progress, sharing updates with family members and healthcare providers as necessary.
- Maintained current knowledge of best practices in personal care through ongoing professional development opportunities.
- Displayed functional familiarity with Medicare, Medicaid and private insurance coverage protocols.
- Maintained up-to-date knowledge of federal regulations governing hospital admissions processes such as Medicare/Medicaid requirements.
Education
Bachelor of Science - Health Administration
Bay Path University
Longmeadow, MA05-2028
Skills
- CMS Audit Preparation
- Medicare Appeals Processing
- Multi-LOB Training & Mentoring
- Workflow Optimization
- Policy Interpretation
- Facets & Jiva Documentation Systems
- De-escalation & Conflict Resolution
- HIPAA Compliance
- Job Aid & Template Creation
- Cross-Functional Collaboration
Timeline
Appeals Specialist
WellSense Health Plan
12.2024 - Current
Resolution Specialist
WellSense Health Plan
03.2024 - 12.2024
Senior Service Specialist
WellSense Health Plan
01.2023 - 03.2024
Personal Care Assistant
Stavros Center For Independent Living
09.2017 - 12.2022
Bachelor of Science - Health Administration
Bay Path University
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