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 targets.-Collaborates cross-functionally to contribute to provider compensation and pricing development activities and recommendations, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.-Responsible for identifying and making recommendations to manage cost issues and supporting cost saving initiatives and/or settlement activities.-Provides network development, maintenance, and refinement activities and strategies in support of cross-market network management unit.-Assists with the design, development, management, and or implementation of strategic network configurations, including integration activities.-May optimize interaction with assigned providers and internal business partners to manage relationships and ensure provider needs are met.-Ensures resolution of escalated issues related, but not limited to, claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information.

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 internal inquiries regarding policies and procedures, credentialing or claims status, orientation activities, and database or portal information or usage. Escalates issues as appropriate.Supports or assists with operational activities that may include, but are not limited to, database management and contract coordination. Performs credentialing support activities as needed. Educates providers on portals, protocols, policies, procedures, and services to enhance the overall provider experience. May assist with or perform standard provider recruitment or contracting or re-contracting functions and discussions.

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 frames; Provide guidance/coaching to front-line staff on specific cases; Identify and trend systemic problems and make suggestions to improve or reduce the possibility of a re-occurrence; Ensure the resolution appropriately addresses all issues raised in the appeal; Communicate issue resolution, orally or in writing; Monitor timeliness and ensure compliance with case work; Identify root cause analysis and trends from appeals; Help improve member satisfaction and health outcomes via the grievance resolution process.

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.• Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability.• Review claims for possible “fraud” and send to Special Investigations Unit for additional investigation.• Process claims and adjustments received through a variety of queries and inquiries; work assignments and procedures can change frequently• Maintain spreadsheets to capture inventory on a daily, or as required basis. Work may come in through emails, queues, escalated issues, etc.• Handle special projects as necessary; track and report on analysis of claims throughout the duration of the special project• Uses thorough knowledge of claims processing and systems to recognize issues, gaps and inconsistencies in workflows, and/or processes; recommends updates, alternatives and/or solutions• Supports production claims work as needed• Serve as a subject matter expert for projects, testing, and validation of claims work process and procedures, etc.

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; Completes audits by the established deadlines; Achieves favorable results through audit accuracy and timely contract release; Monitors and adjusts audit criteria as unit policy is updated; Performs analysis of data to identify and communicate trends; Identifies training needs through audits trends and new Policy and Procedures; Develops and distributes training information; Maintains a TAT of 24 hours for HASTE files and 80% within 48 hours for all other questions; Meets all company-wide and business related training requirements.

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 knowledge; auditing HMO claims for the Reason Code program; assisting the Appeals team with reprocessed claim ID’s in the Complaints and Appeals tracking system; acting as backup for Claims Coach.

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