Appeals and grievance
Resume:
**** **** **** ****** ** # ***
Dallas, TX *****
***********@*****.***
NAMON R CALTON
OBJECTIVE
To obtain a position with a progressive organization who provides opportunities to utilize acquired skills and knowledge as a reimbursement specialist. I seek challenging opportunities where I can fully use my skills for the success of the organization.
SKILLS & ABILITIES
MANAGEMENT
My professional experience has allowed me the freedom to gain a keen sense of responsibility in regards to my management skills. My attention to detail and ability to resolve issues in a competent and hasty manner have afforded me the great fortune of becoming a highly qualified and proficient leader.
Computer Skills
Microsoft office (Word, PowerPoint, Excel), Microsoft Works and Internet, AS400, Salesforce
KNOWLEDGE
ICD-9/10 CODES, HCPCS CODES, CPT CODES
MEDICARE A,B,C AND D, EOB, STD,LTD, FMLA, PRIOR AUTHORIZATIONS AND APPEALS.
EXPERIENCE
BHC APPEALS HCSC BLUE CROSS BLUE SHIELD RICHARDSON, TX
January 2018-Present
Maintains a caseload and monitors day to day compliance of appeal decision time frames.
Review clinical and medical records for completeness and determines administrative or clinical appeal.
Assigns reviews to physician advisors and medical directors for those requiring medical necessity reviews.
Enters all data related to appeals and case reviews into a database.
Participates in data gathering and analysis of reports regarding appeal activity as well as preparing for appeals audits, provides new employee training, monitors QI (Quality Improvement) activities of appeals department, and assists in the development of depart flows and implementations.
Coordinates and distributes first, second and third level appeal request assignments.
Send appeal determination letters to members, providers and the facility.
Responds to member, provider, and client telephone inquiries regarding status, process and outcome of appeals.
STD REPRESENTATIVE LIFE INSURANCE OF NEW YORK PLANO, TX
August 2017-January 2018
Advise customer of eligibility determinations and the status of on-going claims.
Communicate with claimants, employers, and various medical professionals to gather information regarding the application for, payment of, and ongoing management of short-term disability benefits.
Support and promote all integration initiatives (including Family Medical Leave, Life Assistance Programs, Integrated Personal Health Team, Your Health First, Healthcare Connect, etc.)
Handled high levels of call volume from customers and clients. Respond to various written and telephone inquiries, including eligibility, approval/denial determinations, status and continuation or closure of benefits.
REIMBURSEMENT COUNSELOR AMERISOURCEBERGEN CORP FRISCO, TX
June 2013-May 2017
Verifies patient eligibility and conducts complete benefit investigations
Identifies and resolves claims / eligibility issues
Manages an appeal spreadsheet and notifies the program team and managed care department of payer issues related to appeals
Ensures all timelines and customer commitments are met
Assists customers to navigate healthcare insurance reimbursement issues through education, information, and exceptional communication
Supports the Operations Program Manager on program initiatives and departmental goals
Enters insurance and benefit data into the program system
Responds to emails from internal and external customers that need to be addressed immediately by a reimbursement / appeals specialist
INSIDE SALES-IHD FRONTIER COMMUNICATION ALLEN, TX
April 2012-May 2013
Handled high volume of inbound calls related to internet/network issues
Resolved issue with internet connection and network issues
Used remote access to configure modems, remove viruses and installed virus protection.
Upsold company products and service to meet monthly sales quota.
Retained customer from canceling and upsold company products that meet the customer needs.
LOAN COUNSELOR COLLECTION GMAC DALLAS, TX
October 2011-April 2012
Made outbound Collection Calls
Contact delinquent borrowers in order to determine reason for delinquency, update application data, secure current financial information, and obtain commitments for repayment or determine best resolution to mitigate losses.
Maintain call control by overcoming objections; utilizing motivators and listening skills to bridge communication gap with the borrower.
Initiate workout programs to prevent foreclosures, analyze mortgagor’s financial statements, evaluate debt ratios, review mortgagor’s payment record and educate borrowers on alternative money sources/payment options to bring loan current. Work with borrower to reach a solution.
Perform skip tracing on all no-contacts utilizing (application data), internet skip tracing WEB sites, fact finding with third parties and determining best time to call.
Recommend Loss Mitigation referrals upon reviewing breach validation, and, analyze feasibility of short sale or long-term repayment plan to mitigate losses.
TEAM LEAD/CSR UNITED AMERICA INSURANCE MC KINNEY, TX
April 2008-October 2011
Handle all escalations professionally and with a sense of urgency to ensure customer satisfaction
Coach and mentor employees as well as maintain periodic performance reviews
Communicate effectively within work groups and team meeting
Monitor and drive quality goals and objectives
Develop and drive improvement initiatives
EEDUCATION
COLUMBIA SOUTHERN UNIVERSITY BACHELOR OF SCIENCE STILL ATTENDING
Major: Business Administration.
Concentration: Accounting.
COMMUNICATION
Ability to communicate effectively with individuals from many different cultural backgrounds because of educational as well as personal experiences.
LEADERSHIP
2008-2011 Team Lead for United American Insurance.
REFERENCES
AVALIABLE UPON REQUEST
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