Vanessa Powers
Philadelphia
Summary
Experienced healthcare professional with over 10 plus years of experience in Medicare Sales, insurance appeals processing, medical coding and preauthorization. Proven ability to interpret clinical documentation, ensure coding compliance, and collaborate with providers across diverse healthcare settings. Solid foundation in ICD-10-CM/ICD-10-PCS and CPT coding, data analysis and healthcare compliance. Actively pursuing a Revenue Cycle Representative role with a focus on data quality, coding guidelines and denials management.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Surgical Operating Room Technician
United States Army Reserves
- Company Overview: (Honorable Discharge)
- Delivered sterile technique and procedural support in a faced paced, acute care environment.
- Strengthened clinical focus, time management, and cross functional teamwork under pressure.
- (Honorable Discharge)
UM Appeals Specialist
Jefferson Health Plans
01.2022 - 07.2025
- Prepared all case clinical documentation and guidelines for appeal submissions, supporting DRG audits and claim validation efforts.
- Ensured HIPPA compliance and confidentiality with state and federal regulations, including CMS standards for appeals and utilization management.
- Managed provider appeal hearings; Facilitated 1st and 2nd level hearings and presented clinical justifications effectively.
- Utilized multiple Independent Review Organization (IRO) portals for submission of clinical appeals requiring matched specialty reviews. Review IRO recommendations upon completion, interpreted recommendations to resolve discrepancies.
- Queried providers to clarify documentation discrepancies, which improved CMI accuracy and DRG assignment outcomes.
- Drafted appeal determination letters with a strong clinical rational and aligned them with internal compliance practices.
Medical Management Coordinator
Jefferson Health Plans
09.2015 - 12.2021
- Carried out seamless processing of preauthorization requests for medical acute care setting procedures.
- Adhered to payer guidelines and coding protocols, optimized preauthorization process, and determined appropriateness of cosmetic, investigative, and experimental procedures.
- Facilitated professional development by knowledge sharing coding updates and insurance guidelines changes across team members.
- Ensured case documentation with state and federal policies and regulatory compliance deadlines in order to respond to providers’ request.
- Assessed medical policies and InterQual on pended cases to determine need for medical necessity with cosmetic, investigative, and experimental procedures.
- Supported the management team with data analysis and reporting, using Excel to track approval metrics and performance trends.
- Recognized for respectful communication with both internal staff and external providers in high volume environments.
- Managed claim adjustments, write-offs, and balance transfers as part of denial resolution and appeals workflows.
Medicare Marketing Representative
Independence Blue Cross
01.2006 - 05.2014
- Managed a high-volume caseload of approximately 75 Medicare Advantage applications monthly, ensuring accuracy, timeliness and full adherence to CMS guidelines, state laws, and regulatory requirements.
- Executed targeted marketing strategies to drive enrollment in Medicare Advantage and commercial insurance plans, contributing to overall company growth and client retention.
- Elevated clients’ relations by establishing credibility, discerning needs and providing appropriate coverage recommendations.
- Advised clients on eligibility for Medical Assistance and appropriate formulary selections based on individual health needs and coverage preferences.
- Ensured regulatory compliance by following established SOP’s, supporting compliance reporting, and contributing to risk mitigation efforts through accurate documentation and process adherence.
- Officially commended for collaboration, customer focus, highest quality of calls and being a results-oriented person in performance evaluations.
- Collaborated with leadership during internal investigations and external audits, supporting risk assessment efforts and recommending corrective actions where needed.
- Recognized in performance evaluations for excellence in healthcare compliance, call quality, team collaboration and results orientation.
Education
Certified Coding Specialist, CCS -
American Health Information Management Association (AHIMA)
04.2025
Bachelor of Science - Liberal Arts, Minor: Medical Coding
Peirce College
Philadelphia, PA08.2024
Skills
- ICD-10-CM/ICD 10-PCS
- CMS & Compliance Practice
- Critical Thinking Skills
- Math Skills
- Pre-authorization & Appeals Processing
- Revenue Integrity
- HMO/PPO/Medicare/Medicaid
- Microsoft Word
- Microsoft Excel
- Medicare Insurance
- Strong Analytical Skills
- Anatomy & Physiology
- Healthcare Regulations
Certification
- Resident Producer, Individual Broker License, Accident and Health Insurance, PA, NJ, WV
- Resident Producer, Individual Broker License, Life and Fixed Annuities, PA
Military Experience
Surgical Operating Room Technician, United States Army Reserves, Honorable Discharge, Delivered sterile technique and procedural support in a fast-paced, acute care environment., Strengthened clinical focus, time management, and cross-functional teamwork under pressure.
Affiliations
- American Health Information Management Association
AHIMA
Certified Coding Specialist
Timeline
UM Appeals Specialist
Jefferson Health Plans
01.2022 - 07.2025
Medical Management Coordinator
Jefferson Health Plans
09.2015 - 12.2021
Medicare Marketing Representative
Independence Blue Cross
01.2006 - 05.2014
Surgical Operating Room Technician
United States Army Reserves
Bachelor of Science - Liberal Arts, Minor: Medical Coding
Peirce College
Certified Coding Specialist, CCS -
American Health Information Management Association (AHIMA)
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