Reimbursement Specialist/Office Manager Resume Example
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REIMBURSEMENT SPECIALIST/OFFICE MANAGER
Summary
Dynamic and motivated professional with 15+ years of experience in healthcare administration. Proficient in tracking, appealing and resolving denied claims. Detail-oriented, multi-tasking with critical thinking and strong ability to identify, analyze and solve problems. Organized, versatile and able to work independently and in team environment.
Skills
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Experience
Reimbursement Specialist/Office Manager11/2000 to 08/2003Change Healthcare Inc.De Kalb , IL
- Collected and reviewed all patient insurance benefit information. Completed and submitted all necessary insurance forms in a timely manner as required by all third party payers for prior authorizations. Tracked and followed up on prior authorization request
- Provided exceptional customer service to internal and external customers; resolved any customer requests in a timely and accurate manner; escalated complaints accordingly
- Maintained frequent phone contact with provider representatives, third party customer service representatives, and pharmacy staff
- Reported any reimbursement delays to employer/physician. Processed any necessary insurance/patient correspondence
- Collected all necessary documentation required to expedite prior authorization request. This includes demographic, authorization/referrals, National Provider Identification (NPI) number, and referring physicians
- Exercised judgment within defined standard operating procedures to determine appropriate action
- Performed related duties as assigned
Reimbursement Specialist08/2003 to 05/2006HcaLargo , FL
- Verified insurance eligibility and patient benefits to optimize reimbursement and customer satisfaction. Answered questions from the patients, clerical staff and insurance companies
- Identified network providers, provider restrictions, and co-pays as needed. Maintained payer profiles by recording payer specific data promptly into the system
- Obtained authorizations in a timely and correct manner. Ensured authorizations monitored for expirations/renewals
- Prepared and submitted claims, followed up on claims, denials, payer correspondence and authorizations. Documented activities appropriately in progress notes
- Managed A/R monthly and alerted manager about problem accounts (>60 days). Performed various collection actions including contacting patients by phone, correcting and resubmitting claims to third party payers
- Monitored and updated Medicare, Medicaid and private payer policies and guidelines. Maintained the census
Appeals Specialist05/2006 to 02/2008Department Of EnergyUmatilla , OR
- Reviewed assigned denials and EOB's for appeal filing information, gathered any missing information. Reviewed case history, payer history, and state requirements to determine appeal strategy. Obtained patient and/or physician consent and medical records when required by the insurance plan or state
- Reviewed, analyzed and resubmitted denied claims, underpaid claims, and claims that are inaccurately processed
- Created appeal letters with supporting documentation and mailed them. Worked to minimize third party payer denials
- Monitored and followed up on appeals throughout entire process. Maintained accurate, clear, timely documentation related to denied cases. Identified billing-related issues and worked with payers, physicians and staff to resolve issues in a timely manner
- Resolved denial and appeal complaints from patients, insurance companies and other offices for medical-related services
- Responded to patient and family inquiries regarding denials. Acted as a patent advocate by identifying the path needed to obtain the maximum reimbursement under the insurance plan and work with the patient to get the denial overturned
Contract Specialist03/2008 to 07/2018Option Care Enterprises Inc.City , STATE
- Created and built the third party payer contract agreements in the pharmacy operation system (CPR Plus). This includes creating insurance plans, researching and inputting business rules, and loading the contract pricing terms for implementation
- Maintained assigned payer agreements. Updated and executed any changes to pricing, coding, or business rules
- Worked with the Contracting and Revenue Cycle Management on site integration to insure proper insurance plans are accounted for, and assigned to the correct location
- Identified contracts that are not generating revenue to see if there is an opportunity to purge records and reduce plan selection errors
- Audited third party agreement pricing tables to ensure accuracy to improve Revenue Cycle Management success
Education and Training
Bachelor of Arts: Small Business Administration And Management1995International School of ManagementCity
Reimbursement Specialist: Medical Insurance Billing And Reimbursement2000Mildun Training Center of IllinoisCity
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Resume Overview
School Attended
- International School of Management
- Mildun Training Center of Illinois
Job Titles Held:
- Reimbursement Specialist/Office Manager
- Reimbursement Specialist
- Appeals Specialist
- Contract Specialist
Degrees
- Bachelor of Arts : Small Business Administration And Management 1995
Reimbursement Specialist : Medical Insurance Billing And Reimbursement 2000
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