Authorizations Appeal Specialist resume example with 13+ years of experience

Jessica Claire
, , 100 Montgomery St. 10th Floor (555) 432-1000,
Professional Summary
Dedicated Revenue Cycle Management professional with a strong emphasis on facilitating a positive customer experience in the complexities of health insurance coverage. Extensive experience submitting and collecting on medical, and pharmacy claims to commercial and government payers to plans in all 50 states. Expertise in HIPAA compliant electronic transactions involving claims transmission, enrollment in Electronic Funds Transfer and access to Electronic Medical Records at other health systems (EMR). Excel in advocating for patients with passion and commitment. Effectively manage multiple, high-priority projects and strong ability to work in a face paced environment.
  • Insurance policy coverage knowledge
  • Benefits review
  • Healthcare Common Procedures Coding System (HCPCS)
  • Revenue Cycle Management
  • Claims Documentation
  • Prior Authorizations
Work History
05/2016 to Current Authorizations Appeal Specialist The Tampa General Hospital Foundation Inc | Wesley Chapel, FL,
  • Resolve prior authorization denials through written appeals to medical insurance carriers, including group health plans, individual marketplace, and Managed Medicare & Medicaid programs in all 50 states
  • Perform medical record review for assigned cases and identified and requested additional documentation needed according to Plan medical policy
  • Coordinated with internal and external customers to obtain all documentation needed to strategically and effectively submit formal and informal appeals in collaboration with patients
  • Outcomes:
  • Achieved high overturn of denials, 71% success rate (average team rate 56%)
  • High level written and verbal communication with medical doctors and advanced nurse practitioners
  • Translated clinical data from peer-reviewed medical journals to convincing and easy to understand case for coverage
  • Created internal database of peer reviewed journal articles in EndNote, enabling efficient timely access to relevant information
  • Demonstrated consistently high levels of productivity, regularly exceeding established performance metrics
04/2012 to 05/2016 Senior Reimbursement Specialist Costar Group, Inc. | Singapore - Str, DC,
  • Train new Reimbursement Specialists on company's practice management software and provide ongoing day-to-day support in fielding questions and acting as liaison between employees of department and management
  • Assist with developing new processes/procedures to better streamline business and cash flow
  • Work closely with Contract Management to ensure pricing is up to date
  • Responsible for all Medicare patients in ensuring compliance with applicable coverage criteria and working closely with Clinical, Customer Care, and Insurance Specialists to ensure timely reimbursement
  • Outcomes:
  • Increased electronic claim submission from 46 to 86% within nine-month time frame
  • High level of overturn rates when appealing claim denials (89% of appeal submissions resulted in overturn)
  • Nominated by direct-Supervisor and management team to represent Department in Process Improvement Committee headed by CFO and outside consultants
08/2009 to 04/2012 Accounts Receivable Specialist II Bioscrip Pharmacy Services | City, STATE,
  • Submit claims in timely and accurate fashion to reduce denials and ensure correct levels of reimbursement
  • Research and analyze claim and payer specific issues in cooperation with Collections department
  • Collaborate with Contracts & Pricing department through submission of weekly contracted versus billed pricing discrepancy reports to track reimbursement trends
  • Work in concert with Business Support in pre-production testing of electronic submission of primary and secondary claims to previously paper-only payers
  • Communicated received Medicare audit requests to appropriate personnel to ensure timely and accurate response
  • Outcomes:
  • Ensured accurate and timely submission of medical claims to insurance carriers, including all Blue Cross and Blue Shield plans, UHC Oxford and Medicare
  • Assisted in troubleshooting HIPAA 5010 related claim and reimbursement issues
  • Detailed working knowledge and understanding of commercial and government insurance billing practices and procedures
  • Selected by management to serve as primary Medicare biller responsible for final review of claims compliance prior to submission
  • Demonstrated consistently high levels of productivity, regularly exceeding established performance metrics
  • Regularly received exemplary semi-annual performance reviews from management
Expected in 2007 B.A. | History Winona State University, Winona, MN GPA:
GPA: 3.8/4.0

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Resume Overview

School Attended

  • Winona State University

Job Titles Held:

  • Authorizations Appeal Specialist
  • Senior Reimbursement Specialist
  • Accounts Receivable Specialist II


  • B.A.

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