Marquila Miller

Reviewed member cases for medical necessity, eligibility, and benefit coverage aligned with CMS and plan/internal guidelines, supporting care coordination and follow-up needs. Investigated member concerns and drafted regulatory correspondence, including Notice of Action and determination letters.

Processed member appeals and grievances to support timely resolutions in accordance with regulatory, CMS, Medicaid, and plan requirements. Reviewed authorization and benefit/clinical criteria and drafted acknowledgment, determination, resolution, and Notice of Action letters.

Reviewed appeal, grievance, and claims-related cases for completeness, regulatory accuracy, and benefit interpretation with required documentation. Prepared compliant case summaries and correspondence to support clinical review, external review, or internal escalation.

Supported claims, appeals, benefit interpretation, and authorization-related workflows for Medicare, Medicaid, and commercial members. Researched claim denials and eligibility/authorization history and prepared compliant member/provider correspondence using approved templates.

Resolved member and provider inquiries related to claims, eligibility, benefits, denials, appeals, and prior authorization. Reviewed plan documents and account/claim history, created detailed case notes, and supported letter-driven workflows for follow-up actions.

Supported commercial and government appeals and grievances by reviewing case files, intake details, benefit language, and member communications. Helped draft and quality-check acknowledgment, determination, resolution, and Notice of Action correspondence and tracked due dates and documentation needs.

Reviewed pharmacy appeals for medical necessity, formulary compliance, prior authorization requirements, and coverage determination accuracy using PBM and health plan guidelines. Maintained detailed documentation and communicated appeal outcomes and next steps to members, providers, and internal teams.

Processed Medicaid claims and inquiries related to eligibility, benefits, and providers while applying program guidelines and internal documentation standards. Drafted and supported templated written correspondence, including Notice of Action-style communications, and collaborated internally to resolve complex issues.

Managed high-volume provider inquiries related to claims processing, billing discrepancies, eligibility verification, authorization status, and benefit interpretation. Researched claims history and provider records to resolve escalations, support accurate claim outcomes, and train staff on claims systems and documentation standards.

Assisted members and providers with claims, appeals, benefits, eligibility, authorizations, denials, and plan coverage questions across healthcare lines of business. Interpreted plan documents and routed complex appeal/grievance concerns while supporting compliant correspondence workflows in a high-volume environment.

Processed prescriptions in a high-volume PBM environment by performing medication data validation, prescription review, and quality assurance checks. Supported compliance with pharmacy regulations and HIPAA while assisting pharmacists and healthcare teams to reduce dispensing-related errors.

Provided patient-centered support for prescription processing, medication preparation, refill coordination, and pharmacy-related member inquiries in a retail pharmacy setting. Supported inventory monitoring and maintained accurate patient records while ensuring HIPAA and pharmacy compliance.

Conducted prior authorization reviews and medication benefit evaluations to support coverage determination accuracy and compliance with plan guidelines. Analyzed member eligibility, formulary coverage, and medication history, documented case activity in internal platforms, and communicated authorization requirements and next steps professionally.

Continuing education focused on healthcare operations and regulatory compliance, as listed from March 2025 to present.

Completed coursework at Everest College from 2008 to 2009, as listed.

Enrollment at Stepful Inc in 2026, as listed.