Resolution Specialist Enrollment
Resume:
Sandy Lou Payne
(Palm Bay, FL)
Summary:
●Sandy has 5+ years of experience as a SOS / HEDIS, Project Coordinator HEDIS, Resolution Specialist, Financial Resolution Specialist and Coordinator HEDIS.
●Experienced in assisting the Manager in the coordination and preparation of the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review.
●Participates in meetings with vendors for the medical record collection process. Assists Manager with medical record vendor oversight.
●Proficient in assisting Manager in training abstractor staff and participates in the medical record IRR.
●Collects medical records and reports from provider offices based on member needed services reports and gaps and loads data into the HEDIS application.
●Call providers to verify mailing address and phone number and patient demographics, Fax HEDIS information to that provider.
Skills:
●HEDIS
●Medical records
●Microsoft office
●Spreadsheet
●PowerPoint
●Problem solving
●Communication
●Emdeon
●Invison
●SSI
●OMNI
●EPIC
●AS400
●Heron
●Enrollment specialist
●A/P-A/R Specialist in accounting
●Salesforce
●QSHR
●Ilead
●Iset
●EMR
●Medical Records
●CIOX< Change Healthcare
Education:
Phyllis wheatley high school - Huston, TX 1971
High School Diploma
Professional Experience:
UHC Atlanta, GA Jan 2017 to Nov 2022
SOS / HEDIS Remote
●Rate, scrub census, email for missing information for AE’s and sales team
●Enter medical health plans and summaries for case load
●Assists the Manager in the coordination and preparation of the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review.
●Participates in meetings with vendors for the medical record collection process. Assists Manager with medical record vendor oversight.
●Assists Manager in training abstractor staff and participates in the medical record IRR.
●Identifies member service gaps based on data loaded in the MHI HEDIS application.
●Collects medical records and reports from provider offices based on member needed services reports and gaps and loads data into the HEDIS application.
●Sent out proposals/exhibits to Brokers and Sales Team
●Ran 2 applications to send rating/underwriting team for case also completion and preliminary proposals
●for medical insurance
●Run FQT in Salesforce for Rating and Underwriting
●Keep all information logged into WITT
●Keep Omega updated
●Call providers to verify mailing address and phone number and patient demographics
●Fax HEDIS information to that provider
●Receive faxes from providers, managed over 100-20 per week providers
●Make corrections to any sensitive information in the system and request the correct patient information
●Faxed lab test, measures, and eye test, child vaccines, diabetes, blood pressure, correct provider information, to the indexing team
●Participates in special projects and performs other duties as required
●Worked on QSHR, Iset, Ilead, EHR, EMR, EPIC, and requested medical records as needed.
Optum 360 - Atlanta, GA Jan 2017 to May 2017
Project Coordinator HEDIS Remote
●Call providers to verify mailing address and phone number
●Fax HEDIS information to that provider
●Assists the Manager in the coordination and preparation of the HEDIS medical record review which includes ongoing review of records submitted by providers and the annual HEDIS medical record review.
●Participates in meetings with vendors for the medical record collection process. Assists Manager with medical record vendor oversight.
●Assists Manager in training abstractor staff and participates in the medical record IRR.
●Identifies member service gaps based on data loaded in the MHI HEDIS application.
●Collects medical records and reports from provider offices based on member needed services reports and gaps and loads data into the HEDIS application.
●Receive faxes from providers, managed over 100 providers
●Make corrections to any sensitive information
●Faxed lab test, measures, and eye test information to the indexing team
●Participates in special projects and performs other duties as required.
ABLM Inc- Atlanta, GA Dec 2016 to Jan 2017
Resolution Specialist Remote
●Resolves claim denials.
●Ensures that claims are paid correctly and appeals are completed for any short paid claims.
●Resubmits claims when necessary.
●Works closely with the billing specialists to ensure that all claims are billed properly and communicates
●when the payer requests any specific information regarding the claim.
●Participates in branch management, department and intradepartmental meetings and Performance
●Improvement activities as related to job description.
●Participates in special projects and performs other duties as required.
●Work the admin Denials verify why they denied the claim
●Call the patient to verify their insurance
●Updated the insurance information as needed, clinics and hospitals
●Appling adjustments
Optum 360 - Dunwoody, GA Aug 2016 to Nov 2016
Financial Resolution Specialist Remote
●Resolves claim denials.
●Ensures that claims are paid correctly and appeals are completed for any short paid claims.
●Resubmits claims when necessary.
●Works closely with the billing specialists to ensure that all claims are billed properly and communicates
●when the payer requests any specific information regarding the claim.
●Participates in branch management, department and intradepartmental meetings and Performance
●Improvement activities as related to job description.
●Participates in special projects and performs other duties as required.
●Work the admin Denials verify why they denied the claim
●Call the patient to verify their insurance
●Updated the insurance information as needed, clinics and hospitals
●Appling adjustments
Optum 360 Atlanta, GA Feb 2016 to May 2016
Project Coordinator HEDIS
●Call providers to verify mailing address and phone number
●Fax HEDIS information to that provider
●Receive faxes from providers, managed over 75 providers
●Make corrections to any sensitive information
●Faxed lab test, measures, and eye test information to the indexing team
●Participates in special projects and performs other duties as required
Contact this candidate