Senior Appeals Specialist Resume Example Rehabcare

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

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

Senior Appeals Specialist Resume Example

Resume Score: 80%

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