LaDaisha Forney
@ladaishaforney
Risk Adjustment Coder focused on accurate claims edits, insurance verification, and confidential patient data.
United StatesWhat I'm looking for
I’m a Risk Adjustment Coder and Insurance Verification Specialist who focuses on accurate claims processing while keeping sensitive patient data confidential. I bring strong relationship building and communication skills developed through contacting providers and patients to obtain needed information for treatment and appeals.
Across multiple roles, I validate claims submission details against system data, review outcomes for accuracy, and identify potential quality or fraud issues following established procedures. I work in multi-system environments and support efficient processing by resolving billing irregularities, correcting claim errors, and ensuring documentation meets Medicaid, Medicare, and commercial policy requirements.
In HCC coding and claims edits work, I review medical records to code diagnoses according to CMS HCC categories, apply hierarchical codes supported by provider documentation, and work denied claims through the appeal process. I also verify Medicare, Medicaid, and commercial eligibility and abstract encounter information based on vendor guidelines to strengthen risk adjustment requirements.
Experience
Work history, roles, and key accomplishments
Medical Claims Examiner
Auxiant
Aug 2025 - Mar 2026 (7 months)
Validated medical claims submission details against system data and reviewed claim outcomes for accuracy and routing for adjustment as necessary. Identified potential quality or fraud issues, contacted providers/patients for information, and conducted reviews using current claims processing guidelines and clinical/program criteria.
Processed medical claims within policy guidelines and reviewed for billing irregularities. Contacted employers/providers to confirm Workers Compensation claim details, assessed medical documentation and coverage to determine reimbursement, and followed commercial insurance medical guidelines.
Reviewed medical records to code diagnoses accurately according to CMS HCC categories and applied hierarchical codes supported by provider documentation. Worked denied claims through appeal steps and resolved claim edit errors so claims could process correctly.
Managed and processed insurance claims by validating information for completeness and remitting payment to providers when coverage applied. Ensured claims received had no missing or incomplete information.
Risk Adjustment Coder
Precision Spine Care
Dec 2020 - Aug 2021 (8 months)
Conducted insurance verification for new patients by calling insurance companies to confirm policy and payment benefits. Abstracted encounter information per vendor guidelines and verified Medicare, Medicaid, and commercial eligibility while ensuring documentation supported risk adjustment requirements using MEAT/TAMPER.
Care Provider
St. Giles Living Center
Nov 2017 - Mar 2020 (2 years 4 months)
Ensured clients’ homes were organized according to individual needs and that required safety measures were in place. Followed prescribed healthcare plans, which could include exercise and administering medication, while providing emotional support and encouragement.
Education
Degrees, certifications, and relevant coursework
Lufkin High School
High school diploma, Upper Secondary Education
Earned an upper secondary education high school diploma from Lufkin High School.
Availability
Location
United StatesAuthorized to work in
Job categories
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