Heidi Dutton Email & Phone Number

Lexington, NC, US

-Negotiates, executes, reviews, and analyzes contracts and/or handles dispute resolution and settlement negotiations with solo and small group providers.-Manages contract performance in support of network quality, availability, and financial goals and strategies.-Recruits providers as needed to ensure attainment of network expansion and adequacy.

Internally supports and contributes to positive provider relationships by handling routine provider service inquiries and problems regarding policies and procedures, plan design, credentialing process or status, and claims or compensation process or status. Supports the maintenance of contract or demographic data.Triages routine provider issues and.

High Point, North Carolina

Responsible for working provider appeals within required time frames, from intake to resolution; manage the life-cycle of the case and communicating the final resolution to the provider or authorized representative; Acknowledge and respond to provider appeals, orally or in writing; Coordinate issue resolution among multiple departments within required time.

Greensboro/Winston-Salem, North Carolina Area

• Respond promptly and accurately to inquiries from Customer Service Professionals, subscribers, providers, agents, brokers, physicians and other commercial insurance carriers regarding claims payments.
• Analyses Member/Provider correspondence to facilitate correct routing and/or processes request on first touch.
• Process a variety of customer transactions that may include suspended claims, inquiries, adjustments and/or correspondence.
• Meet or exceed established quality and performance standards.
• Determine benefit eligibility on suspended claims and review claims history and other information to determine whether suspended claims should be paid, denied, or sent for medical review.
• Identify system problems, including documentation of the issue, recommendation of potential solutions, referral to appropriate technical staff and follow-up to ensure resolution.

Winston-Salem, NC

Winston-Salem, NC

Contract position analyzing and reimbursing claims Medicaid has paid in error, but for which BCBSNC was the responsible payer. Later was trained to resolve EDI claim suspense errors, and then was sent to basic claims training to process claims for the Self-Insured segment.

High Point, NC

Conducts standard quality audits to measure and evaluate compliance with published policies and procedures; Assists in achieving national quality results; takes appropriate actions (FIFO handling, escalations, follow ups, appropriate handling of claims) to avoid/alleviate late claim interest payments; Supports site efforts to exceed financial targets.

High Point, NC

Addressing project requests of the provider community for HMO claims rework; re-processing related claims if necessary, citing Aetna claims policy; identifying provider billing or contract problems and suggesting resolutions to those problems to providers and their representatives, to enable proper claims adjudication; maintaining current claims processing.

Associate Of Science (A.S.), Liberal Arts And Sciences, General Studies And Humanities, 4.0 - Graduated With Honors

Certificate, Accounting, 4.0 - Graduated With Distinction

Activities and Societies: Phi Theta Kappa International Honor Society