Referral Specialist Power Plant
Resume:
Joseph Pete Banks
********@*****.*** 225-***-****
Career Summary
My experience in the Behavior Health and Social Services field
Education
●Masters of Public Administration 2016
Walden University, Minneapolis MN
●Bachelor of Science on Social Work 2007
Southeastern Louisiana University, Hammond, LA
Experience
Accredo Specialty Pharmacy Memphis, TN 12/2020 - 03/2021
Specialty Pharmacy Prior Authorizations
●Handle inbound telephone and written inquiries from pharmacists and doctors regarding prior authorization by screening and reviewing requests based on benefit plan design, client specifics and clinical criteria.Handle inbound telephone and written inquiries from pharmacists and doctors regarding prior authorization by screening and reviewing requests based on benefit plan design, client specifics and clinical criteria.
●Provide information to clients, participants, pharmacists and doctors regarding participants pharmacy benefit, drug coverage and provide accurate procedures for medication exceptions.
● Facilitate resolution of drug coverage issues and pro-actively address, research and resolve issues while maintaining accurate and complete documentation of all inquires for continuous improvement.
●Work collaboratively with other associates and supervisor to ensure that best practices are shared.
● Provide information to clients, participants, pharmacists and doctors regarding participants pharmacy benefit, drug coverage and provide accurate procedures for medication exceptions.
●Facilitate resolution of drug coverage issues and pro-actively address, research and resolve issues while mainta
●Work collaboratively with other associates and supervisor to ensure that best practices are shared.
Centene Baton Rouge, Louisiana
Special Investigations Unit Investigator 04/2020 – 07/2020
●Conduct investigations of potential waste, abuse, and fraud.
●Document activity on each case and refer issues to the appropriate party.
●Perform data mining and analysis to detect aberrancies and outliers in claims.
●Develop new queries and reports to detect potential waste, abuse, and fraud.
●Provide case updates on progress of investigations and coordinate with Health Plans on recommendations and further actions and/or resolutions.
●Assist with complex allegations of healthcare fraud.
●Prepare summary and/or detailed reports on investigative findings for referral to Federal and State agencies.
●Complete various special projects and audits.
W.W. Grainger Baton Rouge, Louisiana
Onsite Service Representative 09/2019 – 04/2020
●Obtain OSHA and TWIC Certification
●Complete training to gain access to chemical and power plant facilities.
●Learn organization specific computer system programs to place orders for customers.
●Attend weekly sales meeting teleconferences with managers and discuss travel arrangements.
●Log visits to customers clients and submit weekly and monthly logs for mileage and travel times.
●Stock and reorder safety equipment for customers.
●Consult with team members to provide assistance on any special projects.
Amerihealth Caritas Baton Rouge, Louisiana
Behavioral Health Rapid Response Care Connector 06/2016– 07/2019
●Guide insure and members on health information benefits and community health resources.
●Standardized quarterly reporting process to meet the needs of the Louisiana Department of Health for PASRR processing.
●Providing utilization management expertise with Pharmacy benefits, hospitalizations, discharges, provider network, and behavioral health specialities.
●Updating the auditing process raised the compliance scores of the PASRR, raising the scores from 75 to over 95 percent quarterly, saving the organization tens of tens of thousands of dollars.
●Achieving the organization’s mission by finding cost savings benefits and to decrease over usage.
●Analyzed metrics used in Regulatory Reporting to identify trends in the population and the usage of benefits.
●Develop workflow management to increase productivity of the team.
●Use the Integrated Health Care Model to assist members with meeting their health care needs.
●Using strategic planning to achieve benchmarks set by Louisiana Department of Health and Corrections with members who are justice involved and reentering into society.
●Identified fraudulent claims and decreased the potential for fraud waste and abuse which resulted in cost savings for the organization.
●Act as subject matter expert on computer interface platforms JIVA, Streamline, FACETS, and IAD for the department.
LA Department of Health and Hospitals Office of Aging and Adult Services Baton Rouge, Louisiana
Program Monitor, Appeals, and Fraud Prevention 02/2015 – 10/2015
●Cost savings year to date from 02-2015 to 10-2015 of approximately 32 Million dollars in fraud, waste and abuse in an 8 month period with initiatives to stop abuse.
●Worked cooperatively with other state agencies, stakeholders, and executive level management.
●Reviewed utilization records and system reports using SPSS, SPL, Excel, Word, and SharePoint.
●Auditing of medical records for appropriate billing as well as determining medical necessity for procedures and billed services.
●Monitored assessments completed by field staff for correctness and compliance with the evaluation standards of MDS-HC (Minimum Data Set – Home Care).
●Reviewed information collected from reporting to determine trends in usage of Long Term Care benefits using and SPSS and SPL.
●Interpreted data from SPSS and format into usable information to present to key management members.
●Performed root cause analysis and development of reports for the interpretation of benefits, claim payments, provider contracting, eligibility review and processing.
●Perform duties as subject matter expert in court hearings in accordance with state and federal CMS guidelines.
LA Department of Health and Hospitals Medical Vendor Administration Medicaid Department Baton Rouge, Louisiana
Medicaid Analyst 09/2013 – 2/2015
●Process Medicaid and Affordable Care Act applications in English and Spanish for renewals.
●Follow updates for policies and procedure on Medicaid application processing.
●Used multiple data systems to determine eligibility for Medicaid.
●Community Outreach to inform the community about the services provided at Medicaid and Medicare.
●Assisted new employees with acclimation to the information systems and case handling procedures and Health Information Portability and Accountability Act (HIPAA) procedures.
Xerox HealthCare Business Solutions Baton Rouge, Louisiana
Information and Referral Specialist 06/2010 – 04/2013
●Complete initial assessment for publicly funded long term care programs.
●Complete call backs for applicants for placement into the programs.
●Provide customer service to callers.
●Community Outreach by providing information about current programs available to public
●Provided and updated information about community resources
Trinity Mental Health Port Allen, Louisiana
Social Work 01/2009 – 09/2009
●Taught Life Skills group sessions and charting of notes in a Mental Health Day Program
●Took Vital Signs of members
●Planned Activities
Behavioral Hospital of Baton Rouge Baton Rouge, Louisiana
Mental Health Technician 02/2005 – 10/2008
●Activities of daily living
Skills
LEADERSHIP TRAINING
●Listening in a Hectic World, Building Trust Under Pressure: The Basic Principles, The Principles and Qualities of Genuine Leadership, Speaking to Influence Others, Resolving Conflicts With Your Peers, Customer Service Fundamentals 1 &2, Derivative Contracts: Futures, Forwards, Swaps and Options, Negotiating Contract Terms, and Providing Constructive Feedback.
CERTIFICATIONS
●MDS-HC Minimum Data Set Home Care State of Louisiana 02/2015- 02/2018
●Mental Health First Aid (Adults and Children) National Council for Behavioral Health, Maryland Department of Health and Mental Hygiene and Missouri Department of Mental Health 05/2017 – 05-2017
●OSHA Certification
●TWIC Certification
COMPUTER PROGRAMS
●Expert in Microsoft Office Programs (Word, Excel, Access and PowerPoint)
●Knowledge of the program P2K, ADP, and Premiere
●Attended Grant Cardone Sales Technique training classes
●JIVA Medical Records, Case Management, Streamline, Client Data and FACETS
●LASES (Child Support), LDET (Unemployment), MEDS, UNISYS and LAMI (Medicare and Medicaid) Unisys
●SPSS Programing Language
●SharePoint information sharing
●SAP
VOLUNTEER
●Baton Rouge Food Bank November 2015 (60 Hours)
●Alfred C. Williams state representative campaign 7/2011 to 11/2012 (160 hours)
●Volunteer for back to school supply give away (8 hours)
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