Tonya Guess
Mt. Washington,KY
Summary
Experienced manager with strong analytical problem-solving skills and a talent for team building, leadership, and motivation. Possess excellent customer relations aptitude and relationship-building skills, which contribute to the ability to positively impact company success through independent decision-making and sound judgment. Dedicated to applying training, monitoring, and morale-building abilities to enhance employee engagement and boost performance.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Manager, Payment Integrity, CCM Medical Record Review
Humana
03.2023 - Current
- Led remote associates in Communications, Collaboration and Financial Performance
- Monitor performance of vendors by reviewing their financial savings and conducting monthly Key Performance Indicator meetings
- Analyze and interpret claims data for identifying incorrect billing trends
- Conducted research to implement new review concepts
- Adept at using strong investigative and critical thinking skills to assist Medical Director with concept research
- Utilize strong collaborative skills to help promote knowledge sharing and strengthen departmental clinical review concepts
- Spearheaded an idea to update a claims payment policy that yielded ~$1M in increased financial savings through researching industry trends
- Managed and motivated employees to be productive and engaged in work.
- Accomplished multiple tasks within established timeframes.
- Developed a strong company culture focused on employee engagement, collaboration, and continuous learning opportunities.
- Recognized for a Star Award for team work and collaboration
Manager, Nurse Audit Review
Humana
11.2017 - 03.2023
- Led a team of 10 Registered Nurses in Medical Record Reviews
- Familiar with National Coverage Determination (NCD), Local Coverage Determination (LCD), Centers for Medicare and Medicaid Services (CMS) and Food and Drug Administration (FDA) regulations
- Created and implemented new process for annual review of medical codes
- Designed training documents to facilitate learning of the new claims review system
- Optimize Clinical Medical Concepts through Industry research
- Collaborate with colleagues on strategic initiatives to improve inventory
- Recognized for a Star Award for collaborative efforts in process creation to facilitate the adoption of a new system
Manager, Enrollment and Billing
Anthem Blue Cross Blue Shield
05.2004 - 11.2017
- Led 38 remote employees across multiple systems to implement changes to member’s policies and post/balance cash to accounts
- Designed new layout for claims processing system by following the CMS 1500 outline to increase keying efficiency, prevent calculation and keying errors
- Trained business partners, vendors and associates in the classroom and virtually as needed to meet business needs in processing policy changes and addressing individual plan member’s questions
Education
Master’s Degree - Management, Leadership
Strayer University
Washington, DC12.2021
Bachelor’s Degree - Business Administration, Health Care Administration
Strayer University
Washington, DC01.2011
Associate Degree - Healthcare Reimbursement Specialist
Spencerian College
Louisville, KY01.2005
Internship - Medical Coding
Dr. Beverly Gains, MD Pediatrics
Louisville, KY12.2004
Skills
- Decision-making
- Complex Problem-solving
- Verbal and written communication
- Documentation and reporting
- Strategic planning
- Operations management
- Cross-functional teamwork
- Key performance indicators
- Policy and procedure development
- Inventory management
- Vendor management
- Teamwork and collaboration
- Effective communication
- Relationship building
Degrees
- MS
- BBA
- AAS
Certification
CPC, Certified Professional Coder
Timeline
Manager, Payment Integrity, CCM Medical Record Review
Humana
03.2023 - Current
Manager, Nurse Audit Review
Humana
11.2017 - 03.2023
Manager, Enrollment and Billing
Anthem Blue Cross Blue Shield
05.2004 - 11.2017
CPC, Certified Professional Coder
Master’s Degree - Management, Leadership
Strayer University
Bachelor’s Degree - Business Administration, Health Care Administration
Strayer University
Associate Degree - Healthcare Reimbursement Specialist
Spencerian College
Internship - Medical Coding
Dr. Beverly Gains, MD Pediatrics
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