Management Insurance

KEITH MURPH

***** ****** ***** ***** #*** Tampa, FL 34115

Phone: 813-***-**** Email: ********@*****.***

Dynamic, multi-faceted professional with 20 years of experience in the healthcare industry. Consistently recognized for achievement and performance in proven leadership capabilities include. Areas of expertise include:

Office Management

Strategy / Development

Auditing / Compliance

Budgeting

Project Management

Account Management

Quality / Process Improvement

Microsoft Office

Effectively and diversely communicate with all levels of management, peers, staff, and clientele. Special abilities include outstanding organizational, logistic, and analytical skills coupled with world-class interpersonal and communication skills.

PROFESSIONAL HIGHLIGHTS

Laser Spine Institute, Tampa, FL January 9, 2014 - Present

Billing and Appeal Claims Specialist

The Appeals Specialist is responsible for researching, disputing and appealing both paid and denied claims, identify trends or patterns with insurance carriers. May reconcile difficult accounts and conduct specialized research projects.

Manage insurance claims and appeals

Calls patients when insurance checks are sent directly to the patient to obtain payment as well as answering any specific questions post-surgery

Works with billing software and identifies errors and correcting errors if necessary.

Explanation of benefits – Claims management

Confirm insurance coverage and obtains authorization

Track and monitor payer volumes by line of business on a monthly basis and be aware of any reimbursement issues related to contracts; work with payer and internal partners to resolve contract reimbursement and other performance issues.

MEDS Florida Hospital of Carrollwood, Tampa FL March 2013 – August 2013

Medicaid Case Worker (Emergency Room) - Compliance Specialist

Assist with counseling, housing services, food access, etc.

Improved care and programs available for community members with Medicaid.

Interviewed individuals and families to determine if they qualify for Medicaid or Disability.

Received personal data: ID, Bank Statements, Check Stubs, etc.

Entered documentation in the Medicaid and the Social Security Administration database to start the application process.

Provided plans of action to ensure that the Patient and Medicaid have what is needed to qualify and/or pay for the bill of the Emergency Room.

Submitted Bill Tracking Amounts (ER Bills) to Medicaid for processing.

Scheduled interviews for patient with Medicaid and SSI.

Published reports on the efficiency and quality of community services

Express Scripts, Orlando, FL October 2012 – February 2013

Eligibility and Benefits Specialist - Compliance (All Insurances)

Managed inbound and outbound calls related to setting up specialty medication orders; working with medical providers, customers, and other pharmacy staff to ensure patients receive specialty medication in a timely manner.

Researched to see if the pharmacy benefits would be paid by the insurance (interlock) or if there were a PBM – Ex: (MEDCO or Express Scripts.)

Adjudication Rejections: Refill to soon, High Dollar Claim Overrides

Prior Authorization: Completed and faxed forms to the insurance company or to the PBM for approvals or over-rides.

Denials: Research the insurance company (or) with the PBM to verify the process for submitting appeals or over-rides.

Collaboratively with the eligibility team to reach the proper solutions for management of all facets of enrollment into ESI Prescription Drug Plan (PDP) product.

Created daily/weekly reports for the department (HUB)

Indexing Enrollments, Scripts, and forms in the imaging system to be assigned

HealthPlan Services, Tampa, FL November 2009 – March 2012

Major Accounts & Billing Specialist – Compliance (All Line of Business)

Responsible for all client communications, conflict resolution, and compliance on client deliverables and revenue.

Reviewed all major deliverables (i.e. strategic brief, function spec, tech spec, etc.) to ensure quality standards and client expectations are met.

Ensured client issues were dealt with in an efficient manner, by informing the Account Director of any problems that may arise.

Owned the contract and renewals for new book of business for an existing client.

Billing: Posted live checks, feed files and wire payment to Large Accounts

Reimbursement Claims: STD, LTD, Worksite Products, and LIFE & ADD, vision, dental and medical.

Reimbursement (Audits): Over payments that may have been made by mistake to the client, employee or the doctor’s office.

Collections: Placed claims on hold until payment arrangements could be made.

Worked closely with the project team to maintain a continuous knowledge of project status in order to identify potential issues and/or opportunities within or related to the project.

Ensured processes, procedures, and quality standards were met.

Provided regular two-way communication between the client and team to provide strong representation and to outline the client’s expectations.

Understanding of company capabilities and service, and effectively communicates all offerings to the client.

Reported to the Account Director, providing regular input on all account activity, including status and call reports on a weekly basis

Intake upgrades sales to accounts that can benefit from a bundle package depending on claims, current plan design and rates.

HealthPlan Services, Tampa, FL December 2008 – November 2009

Jr. Business Test & Compliance Analyst (All Line of Business)

Reviewed Business Requirements and functional Specifications to ensure completeness, accuracy, and reasonableness to develop business-focused test scenarios and test scripts.

Prepared business test plans, including definition of testing requirements; testing criteria, test scripts, user acceptance conditions and cycle (end to end) test requirements.

Coordinated and managed the execution of functional, regression and user acceptance testing for all assigned projects. Analyze results as compared business requirements and acceptance criteria.

Monitored testing progress, defect reporting and resolution.

Developed business focused regression test scenarios and test scripts for existing product functionality to ensure errors are not introduced to existing process. Validate and execute test plans prior to releasing the software product to productions.

HealthPlan Services, Tampa, FL October 2006 – November 2008

Special Account Service Representative (Team Lead)

Received calls from group contacts, agents, brokers and employees regarding billing and benefits.

Processed enrollments, credits and or debits for billing

Managed distribution of work and backlog for AIG.

Responded to escalated issues: billing, processing, plan designs, etc.

Worked closely with the AIG Management, AIG VOC, Client Managers, Brokers and Agents to define problems and facilitate process improvement.

Supported the objectives of the team, department and the corporation.

Entry-level administrative and secretarial duties.

Processed Billing Web Enrollments, Faxes and Emails

EDUCATION

Florida License (Affordable Care Act) 2013 – 1369440

Revenue Spine Reimbursement Specialist Certificate 2014

Certified Medical Collector Certificate 2014

Top Performer Award August and September 2014

Contact this candidate