Medical Billing Fast Track, Customer Service Precert, Associate Manag

Glynis E Chapman

Post Appeals Supervisor

Medicare Non Par Post Complaint & Appeals

Lodi, CA 925-***-**** *************@*****.***

OBJECTIVE

Dedicated Appeals Supervisor, who has worked with Aetna for 1 years. Post Supervisor for 1 year and Fast Track Appeals for 8 years. I am committed to serving our company and members. Possess exceptional ability to adapt to changes and calm attitude during high-pressure situations. Proven track record of collaborating with team members to suppress appeal issues and meet timely guidelines. Dedicated to our members, our company, and integrity. Effective at quickly assessing situations and responding with effective solutions.

EDUCATION EXPERIENCE

Penn Foster -High School Diploma

2012 - Online Courses

Castro Valley Adult & Career Education

– Medical Billing & Coding

2012 - Castro Valley, CA

CERTIFICATIONS

Part C Organization Determinations,

Appeals, & Grievances

Certified Medical Billing & Coding

National Center for Competency Testing

2012 – National Certification/Renewed

Yearly

[2023]-[2024]

[Post Non Par Complaints and Appeals Supervisor] [Aetna/CVS] •

[WORK AT HOME]

Supervise team of 20 Coordinators with meeting production and quality. Work on meeting goals and working with them individually to help with enhancing strengths and work on areas they struggle with. Answering questions in group chat (my team is my 1st priority) One on One monthly reviews, Mid year and end of year reviews. Run PIR reports, translation reports, tableau reports to monitor any late cases or cases coming due within 10 days or less. Inventory meetings. Build and Present Power Points for team and group meets alerting the team of any updates, stats or events, Void report. Systems used daily are MHK, HRP, GPS, ECHS.

[2019]-[2023

[Fast Track Senior Coordinator, Complaint & Appeals] •

[Aetna/CVS] • [WORK AT HOME]

Assist our Accenture staff in handling incoming voicemails in the BOT system & faxes in MedHOK from Kepro & Livanta. Create IREs for new appeals in MedHOK, review the SA in MedCompass to check the validity of the appeal, is there an authorization for this facility, has the member been issued a NOMNC. Make outbound call the facilities to reach the appeal contact, confirm member is a patient there, the contact received the appeal notification from the QIO and fax the appeal contact the DENC to deliver to member. Document the appeal in MedCompass to notify the assigned UM. Update the IRE and SA in MedCompass of appeal decision once received from the QIO and depending upon type of decision, create a task to the assigned UM.

Answer questions from coordinators.

Manage personal work email & FTA Management mailbox by assisting RNs with decisions and/or clarity on appeals, questions, portal questions, troubleshooting, uploading documents received.

SKILLS

Excellent problem-solving skills

Verbal Communication

Team Leader

Ability to learn quickly

Critical Thinking

Microsoft Office

Excel

PowerPoint

Review cases for accuracy and provide any coaching/feedback needed. Review workflows and make updates. Provide new ideas to supervisor to simplify our process.

Review new process’s, workflows provided by supervisor before it is rolled out to team.

I have submitted multiple IMAGINE ideas.

Create PowerPoints for team meetings & conduct meetings. Review hospital secondary reviews, DND’s, rescind notices, SNF admit denials, & DENCs when needed.

Systems: MedHOK, MedCompass, HRP, GPS, outlook, Excel, Microsoft Word, CMS Supervisor, ASD, Adobe, PowerPoint

[2015] – [2019]

[Fast Track Coordinator, Complaint & Appeals] •

[Aetna] • [WORK AT HOME]

Handle incoming voicemails in the BOT system & faxes in MedHOK from Kepro & Livanta. Create IRE's for new appeals in MedHOK, review MedCompass to check the validity of the appeal, is there an authorization for this facility, has the member been issued a NOMNC. Make outbound call the facilities to reach the appeal contact, confirm member is a patient there, the contact received the appeal notification from the QIO and fax the appeal contact the DENC to deliver to member. Document the appeal in MedCompass to notify the assigned UM. Update the IRE and SA in MedCompass of appeal decision once received from the QIO and depending upon type of decision, create a task to the assigned UM.

Make outbound calls to QIO if there is missing or information that is not matching.

Make outbound calls to CA IPA’s to advise an appeal has been filed. Once forms are received from facility if their form is outdated per CMS.gov, make a courtesy outreach to advise.

If an incoming voicemail was from a member, an outbound call back would be made to answer any questions they had or direct them to the correct dept.

Manage email

Assist with training multiple new hire classes.

Assist with scrubbing of cases to prepare for CMS audit. I was a part of the launch team for MedHOK and helped test and mentor other analysts during our Go-Live event. I traveled to PA with upper management to assist in rolling out MHK to ensure there were no issues on Go-Live Day. Also help test during any MedHOK system updates.

Outlook

Medical Terminology

Calm under pressure

Review workflows and would suggest updates.

Submitted multiple IMAGE ideas.

Create PowerPoints for meetings.

Systems: Fast Track has changed in many ways since I started, I adapted quickly to these changes & new systems. ATV, Citrix, QuickBase to now MedHOK & MedCompass.

[2006] – [2015]

[Inbound Queue Associate, Precertification] • [Aetna] • [WALNUT CREEK, CA]

Answering calls from the Precertification Queue from Providers, facilities and members. Types of calls were Medical and Behavioral Health. Types of plans handled TRAD, HMO & Medicare. Training new hires, familiarize them with systems, policy and procedures along with call workflows and verbiage. Handling delegated CA IPA logs.

Data Entry, including entering cases for scheduled admissions for inpatient, outpatient, emergent admissions, home health care, DME, intensive outpatient, detox, residential treatment, inpatient mental health, or substance abuse and requesting case managers. Worked in Aetna student Health assisting members with benefits, setting up Predeterminations.

Creating SOE's for services that required Precertification, and tasking to the delegated SM, or Nursing staff for review. Authorizing certain services that were approvable based on the ICD-9/ICD-10 & CPT/HCPC & the member's benefits.

Searching the medical & BH provider, facility, HHC agency, or DME company to determine if they are PAR or Non-Par with the member's plan.

Systems used: ASD, eTums, ATV, ECHS, & RUMBA

**Transitioned to work at Home 2012**

REFERENCES

[ Available upon request]

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