VINCENT KELLY

Insurance Case Manager

San Antonio, Texas, United States

+1-210-***-****

ad1n6y@r.postjobfree.com

SUMMARY

I am a result driven, hands-on team player with more than 15 years of experience in healthcare management, processing and compliance to include Managed Care, Medicaid, Workers compensation, Medicare and Auto claims with end to end knowledge of the healthcare revenue cycle and optimal patient outcomes. QUALIFICATIONS:

Confident in leadership and effective communication, Strong organizational, problem solving, and listening skills

Ability to create a culture of teamwork, building confidence with doctors, hospital case management staff, insurance utilization management staff and patients to reach optimal business outcomes Adapts to changes quickly with strong aptitude based in critical thinking Ability to thrive in fast paced work environments

Strong data entry skills with the ability to fluently navigate keyboard and ten key typing speed 40 wpm Deep understanding of all MS products (Word, Excel, Power point) Expert knowledge in Insurance Criteria, Medical terminology, EMR abstraction, ICD-9/ ICD-10, Diagnosis codes, CPT, HCPC, J-Codes, Pharmacy benefits, DME, claims processing, medical billing, Prior Authorization, Appeals, EOB’s, Denials, Third Party Administrators (TPA), IPA’s, HIPAA and healthcare revenue cycle In depth knowledge of medical device complaint review process to include Decision Tree Adverse Event writing and reporting

Deep understanding of all insurance payers: Medicare, Medicaid, Auto, Workers Compensation, Commercial, Managed Medicare, Managed Medicaid, Non-group, TPA and IPA insurance plan types WORK EXPERIENCE

November 2022-Current

Complaints Management Analyst

Becton Dickenson

United States

Under the direction of the Complaints Management, the Quality System Specialist II, will manage activities and procedures associated with complaints concerning BD products including reviewing customer complaints and potentially filing the Medical Device Reports (MDR’s) associated with complaints to the FDA..

Responsible for the investigation management of customer complaints, which includes performing and writing thorough investigations and reporting Adverse Drug Events to the FDA per federal regulations Complex and thorough writing of Decision Trees for reportable and non-reportable adverse events per FDA guidelines

In depth reviews of cases including patient treatment, facility management of medical instruments and reporting technical services resolution or non-resolution of the complaint cases Manage the entire complaint handling process, from receipt of complaints to resolution, ensuring compliance with company policies and procedures.

Receive and log complaints from various sources into the complaint handling system, ensuring accurate and complete data entry.

Review and evaluate each complaint, verifying the accuracy of information and ensuring that all necessary details are provided for further processing.

Route complaints to the appropriate departments or individuals for further investigation and evaluation, ensuring timely resolution.

Follow established procedures to ensure the proper and timely review of customer complaints, including the filing of Medical Device Reports (MDRs) with the FDA as required. Collaborate with cross-functional teams, including Quality Assurance, Regulatory Affairs, and Customer Support, to ensure comprehensive and effective complaint resolution. Maintain thorough documentation of complaint records, including all relevant details, actions taken, and outcomes, in compliance with regulatory requirements. Identify and analyze complaint trends and patterns, providing insights and recommendations to improve products, processes, and customer experiences.

Stay updated with regulatory guidelines and industry best practices related to complaint handling and customer feedback management.

April 2022-October 2022

Diabetes Processing Specialist

Medtronic

United States

Collaborates with distributors, field sales, and the inside sales teams to ensure sales goals are met Responsible for revenue generation and clean claims billing Captures physician charts, labs, notes or letters of medical necessity necessary to receive Insurance approval

Partner with physicians to appeal rejected submissions for prior authorizations Customer Service advocate with insurance payers

Sets shipment/order processing expectations with physicians Submitting prior authorization request working with utilization management staff to obtain approval of DME Qualify medical necessity based on insurance guidelines and criteria Extensive with Centricity and EMR systems

June 2013-January 2022

Insurance Case Manager

KINETIC CONCEPTS INCORPORATED/3M

San Antonio, Texas, United States

Hired as Customer Service Representative 2013, and then promoted to Senior rep in 2018 Top performer for my department 6 years in a row processing 190+ wound vac orders per month far exceeding company standard of 80 orders per month generating $2-3 million in revenue annually Promoted to the elite holiday team working evening and weekends demonstrating ability to comprehend insurance guidelines from more than 30 states

Establishes and maintains synergy within internal and external relationships Benefits verification across insurance types – workers comp, commercial, Medicare, Medicaid, Non-group and Medicare plus plans

Lead 400K+ reduction in unbilled revenue recovery initiatives through document collection Prequalified patients by in depth medical records review against insurance criteria Prepare and submit authorization requests for insurance review Convey approval or denial determinations to medical staff, field sales team and patients when necessary Coordinated delivery and return of DME equipment

Provided ICD-9/ ICD 10 diagnoses, HCPC and CPT codes to insurance payers In depth knowledge of appeals process, billing and corrected claims process Negotiated contract rates with insurers when no contract was available September 2011-April 2013

Underwriter

BANK OF AMERICA

Dallas, Texas, United States

Hired as an underwriter during the Obama administration for the distribution of TARP funds

• Excelled as a top performing underwriter in very competitive environment with promotion to acting supervisor when management staff was unavailable

• Processed credit reports and investigated applicant history

• Ordered property appraisals for refinance purposes

• Reviewed debt to income ratios to ensure bank and TARP standards were met

• Determined level of risk for applicant refinance

• Provided final approval or denial of loan application

• During my tenure Bank of America Dallas branch had the honor of being #1 in the nation for TARP approvals helping countless borrowers stay in their homes during one of the greatest economic depressions in US history March 2010-June 2011

Mortgage Closer

NATIONSTAR MORTGAGE DALLAS TX

Dallas, Texas, United States

• Analyzed all loan closing packages and paperwork for accuracy including HUD-1

• Accurately processed more than 15 closings per day exceeding company goal by 25%

• Managed and resolved any documentation issues

• Acted as an intermediary between all parties involved in the closing transaction (title companies, underwriters and borrowers)

• Ensured closing details complied with state and federal regulations

• Coordinated mortgage closing proceedings

• Maintained accurate closing schedules - average loan pipeline 100+

• Prepare and execute transfer of lender funds for disbursement

• Entered data on loan closings in the system in a timely manner May 2006-December 2009

Sr. Technical Claims Analyst

COVENTRY HEALTHCARE

San Antonio, Texas, United States

Promoted to Senior high dollar claims processor of hospital claims in 2008

• Analyzed and reviewed medical claims for reimbursement to include office visits, DME, surgical and anesthesia

• Processed more than 30 claims per hour above company standard of 20 with 98% accuracy rate

• Extensive knowledge in CPT and HCPC coding with an depth understanding of HCFA and UB-92 forms

• Verified claims payment complied with contracted rates or UCR

• Processed adjustments for underpaid or denied claims

• Conveyed denial reason to claimants

• Promoted to high dollar hospital claims processing claims in excess of $1 million according to DRG contracted rates

• Assisted in new hire training classes helping to mentor new employees January 2003-March 2006

Mortgage closer

WORLD SAVINGS BANK

San Antonio, Texas, United States

Hired as a mortgage for the distribution of ARM Loans

• Analyzed all loan closing packages and paperwork for accuracy including HUD-1

• Managed and resolved any documentation issues

• Acted as an intermediary between all parties involved in the closing transaction (title companies, underwriters and borrowers)

• Ensured closing details complied with state and federal regulations

• Coordinated mortgage closing proceedings

• Maintained accurate closing schedules -

• Prepare and execute transfer of lender funds for disbursement

• Entered data on loan closings in the system in a timely manner July 1999-November 2002

Customer Service Claims Processor

HUMANA INC

San Antonio, Texas, United States

• Took incoming calls from claimants (patients and vendors) regarding denied or underpaid claims

• Investigated claim denial reason with customers on the phone and providing denial reason

• Adjudicated claims for payment once denial reason had been satisfied

• Provided in depth explanation of benefits (EOB) analysis for policy holders inquiring about patient responsibility

• Performed benefit verification and provided authorization status on requested services

• Assisted patients in finding providers in the Humana network and also out of network for PPO patients

• Also assisted PCP's offices in obtaining referrals for specialist care CERTIFICAIONS AND MEMBERSHIPS:

• Group 1 Life, Health and HMO state license (expired)

• Series 6, 63 and 7 financial licenses (expired)

EDUCATION

-Current

Diploma

Northside School of Innovation

United States

Northside School of Innovation, Technology, and Entrepreneurship

● Diploma

• Technology, and Entrepreneurship

SKILLS

CPT Medical Records NEW Hires Quality System Customer Service Oriented Customer Service ICD Incoming Calls Billing Medical Billing Collection Data Entry Filing TEN KEY Typing 40 WPM Closing Closings HUD-1 Processing Specialist Processor Order Processing Federal Regulations Adjustments Sales Goals Sales Team Time Management Managed Care Medicare Workers Comp Coding ICD-9 Claims Claims Processing Customer Service Claims Medical Claims Processing Claims Technical Claims Commercial Insurance Customer Service Representative Inside Sales Mentor Mentoring Medical Device Benefits Pharmacy Benefits Office Medical Medical Terminology FDA Health Maintenance Organization HMO Medicaid Regulatory Affairs Patient Care Medical Invoicing Loan Closing Loans Mortgage Mortgage Closing Mortgage Closer Closer Disbursement Series 6 Healthcare Medical Instruments HCFA Retail Sales Decision Trees Technical Services EMR Hipaa Best Practices Problem Solving Quality Assurance Confident Documentation ARM Production Management Pipeline Excel

HONORS & AWARDS

During my tenure Bank of America Dallas branch had the honor of being #1 in the nation for TARP LANGUAGES

English - Intermediate

WORK AUTHORIZATION

I am authorized to work in the following countries:

• United States

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