Medicaid/Medicare Health Care Professional with both State and Federal compliance experience, through the delivery of quality client care and health services.
Facets, Cotiviti, Macess, Caremark PBM systems, Jiva, Sanovia, Microsoft Word, Excel, Outlook, PowerPoint, Lotus Notes, Verint, EXP, and Web 2000.
Coordinator of Operations, 09/2013 to Current AmeriHealth Caritas – Philadelphia, PA
Assisting and managing Provider Network Operations staff as necessary to assess and correct issues being encountered by providers and other internal staff.
Conducts routine audits to ensure contractual obligations are being met.
Identifies configuration errors through recovery reports , o monitor cost contatrends with Interpreting and Coordinating and facilitating administrative activities including meetings and material development (P&Ps;, desk procedures, workflows, etc.
Identified areas of waste, abuse, fraud from both external and internal
Assessing and triaging incoming provider issues while maintaining tracking database(s) and ensuring that operational issues are being worked and resolved in a timely manner Preparing high-visibility reports that outline the operational status of key provider escalations and issues Assisting Provider Network Operations staff as necessary to assess and correct issues being encountered by providers and other internal staff; to include submitting requests to various operational areas via Service Form (SF), or other methods, to update provider information, run claim reports or projects, etc.
Analyzing and trending reports to identify outliers and areas of improvement Managing and routing state requests and inquiries to appropriate functional areas while ensuring timely responses Assisting in drafting and/or finalizing formal correspondence to customers Engaging, developing and maintaining multiple customer relationships, establishing trust and open communication Research Analyst/Tele-commuter •Adapted to meet the needs of the business in serving seven different lines of business.
Identified process gaps and trends to formulate solutions geared to assist in process improvement.
Analyzed complex operational claim payment problems and provides technical solutions.
Responded to and resolves provider and health plan claim inquiries through correspondence.
Maintained a current working knowledge of processing rules, contractual guidelines, plan policies and operational procedures to effectively provide technical expertise.
Resolved and provided direction on complex cases through strong investigative and research skills.
Completed pre- and post-disbursement reports.
Interfaced with various health plans to identify solutions for the company and providers alike.
Provided back up support to supervisor with internal emails and correspondence.
Reviewed state encounters for identified claim errors and discrepancies.
Corresponded and documented state findings from First Alert meetings.
Maintained a balance of productivity, quality, and timeliness of job accountabilities.
Served as a subject matter expert as needed.
Research Analyst, 09/2013 to 11/2017 AmeriHealth Caritas – Philadelphia, PA
Interpreted data and made recommendations from findings.
Helped team meet regulatory requirements by coordinating documentation and filings.
Took active role in departmental meetings, engaging with all parties and transcribing detailed notes of plans, decisions and options discussed.
Pharmacy Care Service Technician II/Tele-commuter, 04/2008 to 08/2013 AmeriGroup Corporation – Virginia Beach, VA
Medicaid and Medicare compliant according to State and Federal guidelines.
Management of drug authorizations and lock-in program members through PBM system.
Corresponded Pharmacy and Therapeutic Committee (PNT) decisions.
Reviewed PBM systems for prescription drug claims to ensure medical necessity and appropriateness.
Database entry of pharmaceutical therapies for utilization review.
Educated callers on AmeriGroup's policies and procedures as outlined.
Resolved provider concerns and complaints.
Interfaced with other departments to resolve concerns relating to other benefits offered.
Pharmacy liaison; ensured claims were processed correctly and the patient was able to obtain medication.
Assisted clinical staff with obtaining additional information and served as a liaison for the provider.
Adhered to HIPAA guidelines to ensure member privacy.
Customer Service Representative/IHD, 03/2006 to 09/2007 Coleman and Associates – Norfolk, VA
Provided administrative support to assist in escalated customer complaint scenarios.
Resolved high speed Internet billing questions and or disputes.
Adjusted accounts which may have been incorrectly billed.
Provided clear explanation of bills.
Assisted other representatives with basic knowledge and service updates that impact the center.
Produced outstanding customer service results through customer service index.
Adhered to policy; surpassed the company's goal for ready availability on the switch board.
Project Management CertificationUniversity of Delaware
Bachelors of Arts: Healthcare AdministrationUniversity of Phoenix
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Companies Worked For:
Coleman and Associates
University of Delaware
University of Phoenix
Job Titles Held:
Coordinator of Operations
Pharmacy Care Service Technician II/Tele-commuter
Customer Service Representative/IHD
Project Management Certification Bachelors of Arts : Healthcare Administration
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