Areas of Expertise:

I am a dependable professional with experience in Customer Service, Data Entry, Insurance Verification/Authorizations, Appeal & Grievance Analysis, Senior Claim Examining/Adjusting, and Facets Analysis and Testing.

Education:

Georgia State University, Atlanta, GA Expected Graduation 2016

Bachelor of Arts and Science, Sociology

Work Experience:

Northside Hospital- Galen Advisors 08/2014-currently

Physician Denial Management Specialist

Post payments to accounts and maintain records

Ensure resolution of submitted claims in a time-efficient manner

Submitted claim appeals for review, scheduled initial clinical and concurrent reviews for case managers. Handled Medicare, Medicare replacements, and Medicaid.

Good ability to interpret rules and regulations set by Medicaid, Medicare and commercial insurance payers.

Maintained patient confidentiality and followed the mandates of HIPAA

Updated patient insurance information onto patient's profile

Handled work production through Centricity, e-MD, Avality, Emdeon, and Greenway.

Analyzed claim rejections and denials and draft appeals.

Dell Services -Contracted at Universal American 10/2012-03/2014

HC & Insurance Ops. Sr. Assoc

Identify Non-Par and Par provider appeals.

Conduct initial intake of appeal or grievance as rapid triage and distribute to staff members for processing and resolution.

Identify and Resolve member grievances with prior authorization, Quality of Care/Quality of Service issues.

Forward cases for dismissal to Maximus for review.

Coordinate and communicate with other vital departments like Cost Containment (CCU), Claims, Compliance, Fraud Waste & Abuse (FWA), etc.

Document all calls and correspondence in tracking systems. (SharePoint,C3, Access, FACETS, Macess, Embdeon)

Document all calls in the call tracking systems. (Access, FACETS, Macess)

USA BENEFITS/XPERT MEDICARE 04/2011-08/2012

Grievance & appeals analyst

Review and respond to member/ provider grievance & appeals in writing and verbally according to CMS guidelines.

Member/Provider Appeals, HMO, PPO, Medicare. Communicate in a clear and concise manner, listen to others.

Perform research related to the facts and circumstance of member and provider complaint. All complaints resolved in a timely manner

Document all calls in the call tracking systems. (Access, FACETS, Macess)

HIP of FLA 04/2010-04/2011

CLAIMS EXAMINER

Performed research to respond to inquiries and interprets policy provisions to determine most effective response. (Claim Repository, CMCA, Legacy, Amysis, Diamond)

Take initiatives to resolve unique, complex and unusual claims. Initiates interaction with other areas to ensure claims are handled properly.

Knowledge of contracts and strong knowledge of managed care Benefit Programs.

Skills:

Proficient in Microsoft (Word, Excel, PowerPoint, Access)

Proficient MICROS/POS

Bilingual –Haitian (Creole)

Systems (Facets, Centricity, e-MD, Greenway, Access, Macess, Xcelys, Emdeon, Avality, Payspan, Optum, Amysis, and EncoderPro)

Activities:

Tennis Team 08/2006-05/2009

FBLA (Future Business Leaders of America) 08/2004-05/2008

UM Skills Litigation 05/2005

Teen Court 06/2005-06/2007

Spotlight Campus Event 08/2011-08/2012

Volunteer Services

Coolgirls Inc. 09/2010-currently

Open Hands Atlanta 02/2012

Silver Stocking annually/Holiday

REFERENCES

Indra Andino

Appeals Supervisor

Universal American

Contact: 832-***-****

Bianca Kinloch

Education Specialist

Northside Hospital-Galen Advisors

Contact: 770-***-****

acsm3s@r.postjobfree.com

Caroline Spencer

CTT Manager

Universal American

Contact: 404-***-****

Contact this candidate