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A health care administrator responsible for the development and management of health care operations looking for the chance to become a part of reputed health organization to provide continuous health care services with exceptional analytical, problem-solving, and organizational skills. Demonstrating superior understanding of ICD-9 & 10, electronic medical records CPT coding, DME (Durable Medical Equipment), and Medicare and Medicaid billing procedures. Self-motivated, dependable and professional with 7 years of extensive experience in Pharmacy processing, Pharmacy and Medical billing, collections and medical terminology. Well-developed interpersonal communications skills. Assumes responsibilities with leadership and competence. Able to work well independently with little or no supervision also works well with others in team atmosphere. Ability to multitask with high quality organizational skills and detail oriented.
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- Responsible for new account acquisition and retention.
- Conduct benefit investigations; verify insurance benefits for patient and Clinic.
- Assured timely verification of insurance benefits prior to patient discharge from the hospital.
- Obtained and maintained knowledge of third party billing, coding, medical terminology, prior authorizations and appeal submittals.
- Obtain recertification for cases requiring extended treatment/coverage beyond the expiration of original approval.
- Participate in conference calls with Client Sales Representatives, client management and clinics regarding status of cases, Equipment and supply orders and status of claims.
- Coordinate activities related to contracts, single case agreements, reimbursement outcomes.
- Documented client progress through case notes and documentation.
- Investigated and resolved patient authorizations and claim issues.
- Conduct benefit investigations, verify insurance benefits for patient and physicians' office, and submit and obtain prior authorization as required by payer.
- Analyzed explanation of benefits (EOB's) to detect payment discrepancies and payer trends to determine appropriate follow-up i.e., resubmissions, adjustments and or refunds for varies insurance claims, including worker's compensation, ConnectiCare, United Healthcare, Aetna, and Medicare/ Medicaid.
- Participate in conference calls with Client Sales Representatives, client management and physicians' offices regarding status of cases, drug orders and status of alternative funding.
- Provide coordination of order for product, shipment of product, and therapy initiation with pharmacy and patient.
- Participate in Call Center Activities, triage and respond to incoming calls from patients, insurance companies, physicians, Sales Reps, pharmacies and homecare agencies.
- Served as single point of contact for an assigned group of prescribers.
- Identify and report events as required by the REMS requirements for specified medication.
- Recognize adverse event, product quality complaint and potential risk events and forward information to the appropriate team member for reporting to the manufacturer.
- Educate patients, prescribers, and others regarding program requirements, and facilitate referrals.
- Perform other duties as deemed necessary by the Group Manager.
- Correct and Re-submit rejected Third Party Rejects (TPRs) by reviewing the TPR.
- Interpret Medical Abbreviations (SIG Codes). Read and Review prescriptions.
- Handle inbound and outbound calls with pharmacists, insurance companies, and doctor's offices. Process refill request.
- Read and understand prescription data entry guidelines and procedures.
- Assist the Pharmacists with escalated unresolved TPR.
- Contact the pharmacists to alert them of any changes in patient's condition, compliance issues due to patient not taking medication or side effects, or to transfer a patient directly to pharmacist for counseling.
- Complete other stages of the order process as assigned including but not limited to scanning prescriptions, imagine indexing, pre-QA, load insurance information, process claims, work issues and facilitate prior authorizations.
- Provides typed documentation of all communications received from calls and provide notification of any urgent orders, shipping related issues and any errors.
- Successfully ensures ads and sales planners, and new merchandise is out and are set on time, including setting and correct signs by taking down old signs and putting up new sales signs.
- Supervised, trained, and coach's sales floor team members on service and presentation skills.
- Ensured zoning was completed, abandoned merchandise is restocked, and damaged and rewrap merchandise is handled properly.
- Supervised end-to-end stock management, including examining incoming inventory, merchandising shelves and preventing shrinkage.
- Coached and leads sales floor team in Electronics and Hardlines department through weekly routine.
- Managed recruitment, training and development for highly effective sales team.
- Greeted customers and helped with product questions, selections, and purchases including in-store and e-service transactions.
- Established and optimized schedules to keep coverage and service in line with forecasted demands.
William R Boone High School - Orlando, FL
Valencia College - Orlando, FL
Seminole State College Of Florida - Sanford, FL
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Resume Overview
School Attended
- William R Boone High School
- Valencia College
- Seminole State College Of Florida
Job Titles Held:
- Benefit Verification Specialist
- Senior Reimbursement Specialist
- Resolution Expert
- Sales Floor Trainer
Degrees
- High School Diploma
- No Degree
- Associate of Science
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