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Senior Appeals Specialist Resume Example

Resume Score: 80%

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SENIOR APPEALS SPECIALIST
Professional Summary

Detail oriented, RAC-CT certified Claims and Denials Specialist and licensed occupational therapist with 20 years of successful experience in Medicare/Managed Care regulatory requirements and therapy program management. Recognized consistently for performance excellence and contributions to success in contract therapy industry. Strengths in process improvement, team management, and quality assurance/improvement activities.

Accomplishments

· Co-developed company-wide internal auditing process, facilitating communication and review for independent review organization (IRO) and Corporate Integrity Agreement (CIA).

· Developed centralized ADR/documentation request process and implementated training; resulting in 40% decrease in costly technical denials company wide, and increased efficiency and accuracy of responses to Medicare, Managed Care, and external auditing entities.

Skills
  • Documentation abilities
  • Project organization and management
  • Relationship development
  • Process improvement
  • Adobe, MS Office, Casamba, and Matrix experience
  • Team management
  • Reporting and data analysis skills
  • Training and Development
  • Priority Management
  • Audits and consulting
Work History
Senior Appeals Specialist04/2011 to Current
Rehabcare – Saint Louis, MO
  • Managed client quality assurance programs, including on-site evaluations, internal audits, developing process improvement plans, and providing training to staff and field employees
  • Managed timely response to Medicare and Managed care claims denials, including chart audit, appeal writing, administrative law judge hearing testimony, contract review.
  • Acted as regulatory, billing, and documentation quality subject matter expert, answering internal and external questions and inquiries.
  • Identified quality assurance risk issues and participated in development of mitigation strategies at company corporate level.
  • Worked with skilled nursing and long term care client partners to understand needs and provide appeals and documentation/process quality management training and services.
  • Presented yearly at local, state, and national levels on quality assurance, documentation, and ADR/appeals response topics important to therapists and client partners.
  • Provided employee oversight and training to new employees and support staff.
  • Effectively communicated with staff, including members of operations, finance and clinical departments.
Senior Program Director12/2009 to 04/2011
Rehabcare – Saint Louis, MO
  • Oversaw day to day operations for team of 8 for therapy service delivery.
  • Provided ongoing direction and leadership for program operations to new managers.
  • Interacted with customers and clients to identify business needs and requirements.
  • Addressed and resolved technical, financial and operational concerns by working with team members and directors.
  • Maintained high level of quality service delivery and met operational objectives.
  • Established team priorities, maintained schedules and monitored performance.
  • Engaged with customer partners, patients, and patient family members to create positive, trusting and professional relationships.
Program Manager08/2008 to 12/2009
Hallmark Therapies – Saint Charles, MO
  • Interacted with customers and clients to identify business needs and requirements.
  • Trained and developed personnel to improve safety, employee relations and resolve communication issues.
  • Coached team members on productivity strategies, policy updates and performance improvement plans to accomplish challenging goals.
  • Assessed performance and scheduled cost control while maintaining contractual and internal performance requirements.
  • Addressed and resolved technical, financial and operational concerns by working with team members and directors.
  • Established team priorities, maintained schedules and monitored performance.
  • Engaged with customer partners, patients, and patient family members to create positive, trusting and professional relationships.
Regional Program Manager09/2001 to 09/2008
Aegis Therapies – Jefferson City , MO
  • Identified system needs and designed processes to support business requirements.
  • Mentored and supported 16 department employees across 5 buildings to create strong workplace culture.
  • Engaged with customer partners, patients, and patient families to create positive, trusting and professional relationships.
  • Monitored tools and benchmarks to improve team performance and provided feedback to facility program directors.
  • Networked in local community to identify business opportunities.
  • Trained teams in quality improvement strategies for documentation, patient screening, falls, urinary incontinence, and dementia management topics.
  • Oversight of day to day operations of rehab team in skilled nursing and long term care facility.
Education
Bachelor of Science: Occupational Therapy1999University of Missouri - Columbia- Columbia, MO
  • Graduated magna cum laude
Certifications
  • RAC-CT certified
  • Licensed Occupational Therapist
Additional Information

Recognitions include:

  • Aegis Therapies Master Clinician
  • Hallmark Therapies Mission, Vision, Values Award
  • Rehabcare Core Values recognition in all 6 core value areas
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Resume Overview

Companies Worked For:

  • Rehabcare
  • Hallmark Therapies
  • Aegis Therapies

School Attended

  • University of Missouri - Columbia

Job Titles Held:

  • Senior Appeals Specialist
  • Senior Program Director
  • Program Manager
  • Regional Program Manager

Degrees

  • Bachelor of Science : Occupational Therapy 1999

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