Leighton A. Email & Phone Number

Madison, WI, US

United States

Madison, Wisconsin

Madison, Wisconsin

Platteville, Wisconsin

Madison, Wisconsin Area

• Conceptualized, initiated, and managed implementation of default discount methodology configuration in claims processing system resulting in projected $600K annualized savings across Dean's commercial networks.
• Lead, designed, and implement fee schedule consolidation initiatives in multiple service-specific areas (examples include DME, Flu Shot, and Mental Health reimbursement).
• Managed professional Pay-For-Performance incentive programs.
• Developed business processes for managing: provider service-restriction audits, fee schedule updates, and manually reviewed/priced claims.
• Maintained 300+ physician fee schedules according to governmental regulation, provider contracts, business practices, and audit results.
• Accepted into Lean-at-Dean Six Sigma Green Belt process improvement certification program.

Middleton, WI

• Serve as subject matter expert for questions, concerns, and remediation that require technical research and/or configuration updates.
•  Write and analyze SQL reports to diagnose or determine claim impacts of configuration errors, proposals, and enhancements.
•  Identify and complete function-specific configuration needs.
•  Manage quarterly CPT/HCPCS/DX/PCS code update workflows and system implementation.
•  Design and perform training on configuration and processes used for pricing.
•  Assist with installing, integrating and testing claims system upgrades.

• Analyze and configure all new products, benefits, benefit changes, and authorization requirements.
• Develop and initiate reports auditing claim payments.
• Carry out testing of new and updated configuration changes for accuracy and completeness.
• Conduct Pre-Payable audits for identification of configuration errors or inconsistencies.
• Analyze, configure, and test State and Federal benefit mandates.
• Complete annual review of benefit related materials, Medical Certificate, and Member ID Cards.

Dallas, TX

• Research provider enrollment issues to determine causes and appropriate corrective actions.
• Communicate found issues with Corporate Provider Enrollment team to coordinate solutions.
• Complete provider file update requests with health plans to resolve known provider issues.
• Assess and resolve health plan provider related rejections/denials.
• Review and resolve claim payer edits for provider enrollment issues.
• Complete all non-participating enrollment applications when required for assigned providers.

Richardson, TX

• Review provider files for completeness of information and presence of supporting documents.
• Complete enrollment, re-credentialing, and hospital privilege applications.
• Verify enrollment procedures with health plan and obtain updated applications as available.
• Notify proper departments of provider file updates, new enrollment, and application progress.Hospital Associate Medical Biller
• Create accurate patient accounts through communication with patients and health plans.
• Create and maintain newborn nursery census to comply with internal verification standards.

Master Of Business Administration - Mba, Data Analytics

Bachelor'S Degree, Business Administration, Human Resource Management

Activities and Societies: Kappa Alpha Sigma, Tau Kappa Epsilon, Cheerleading, United Greek Council, & Women's Greek Council