Appeals Specialist Workers Compensation
Resume:
SHARON M. CHANDLER
**** * ******* ****** *****, FL 33603
*****************@*****.***
PROFESSIONAL SUMMARY
A dedicated and knowledgeable insurance professional, with a passion for serving others. I am self motivated, results driven yet personable and a pleasure to work with. I have extensive experience of 20 years in Medicaid and Medicare.
EDUCATION-2007-2012 University of Tampa
EMPLOYMENT
CENTENE HEALTH PLANS June, 2018-October, 2022
Appeal Intake Specialist
Load provider or members appeals into iCP
Contact providers regarding their appeals
Maintain daily production goals
Keep daily production logs by creating excel spreadsheet
Attend weekly meetings via zoom
Work with internal departments to coordinate completion of work queues
WELLCARE HEALTH PLANS. October, 2017-June, 2018
Provider Operations Coordinator
Review expansion contract documents to ensure they are in good order
and configurable
Clear all exceptions and process all PRR Reviews within twenty-four hours
Pull credentialing applications from CAQH by CAQH number, name, or NPI
Evaluate all credentialing documents such as COI, Collabs, CLIA, DEA licenses, etc. to ensure that they are in good order for processing
Create PLF’s for physicians, ancillary providers, and facilities for multiple states and lines of business
Exceed productivity standards for creating PLF’s and scrubbing credentialing documents
Make outbound provider calls for missing items in order to complete a PLF or credentialing packet
July 19, 2016-June, 2017 MOFFITT CANCER CENTER
FINANCIAL SPECIALIST III
Reviewing scheduled appointments, planned surgeries and planned admissions to ensure all aspects of insurance approval have been met for each encounter.
Pay attention to detail as review each patient's treatment plan and insurance benefits to ensure that all information is accurate and that pre-certification or authorization is obtained from the payor and/or primary care physician.
Follows up on errors and offers contributions and suggestions to improve current methods. Contributes innovative ideas to improve work practices and flow.
October, 2016 – June, 2017 ADVENT HEALTH
FINANCIAL SPECIALIST II
Answer inbound calls to the department from patients, attorneys, and insurance companies.
Make payment plans and offer pay in full discounts to patients.
Review account charges and balances with Payers
Mail statements to patients
Properly document each account accessed.
Collect as much possible from payers and patients to reduce outstanding balances.
September, 2015- July, 2016 LAKELAND REGIONAL HOSPITAL
FINANCIAL SPECIALISTS
Verify insurance and process ambulatory surgeries and office specialist appointments for the Cancer Center.
Work from a work-list for my assigned Doctors to clear lists in a timely manner.
Assist Radiology with their work-list when I have completed my list.
Contact patients to verify new insurance information.
Maintain weekly production percentage and logs.
November, 2013 – November, 2014 ELECTRO MEDICAL INC.
MEDICARE/MEDICAID COORDINATOR
Process Intake applications for Medicare patients to receive Durable Medical Equipment
Enter all of the patients Demographics into a data base
Verify patients Medicare status by using CMS website and NEBO
Ensure that the Prescriptions are completed correctly according to Medicare’s guidelines.
Contact providers if corrections are required for the prescriptions
Contact patients outbound via phone or email or mail
Answer inbound calls from providers or patients to answer their inquiries regarding their equipment
June 2012- Sept 2013 TRAVELERS INSURANCE APPEALS SPECIALIST
Review and process workers compensation claims according to work flow
Consistently provide high-level customer service internally.
Review Workers Compensation appeals and process according to denial reasons.
Queue Workers Compensation appeals to be reviewed by Coders
Maintain a production log daily.
Complete assigned task assigned by temp supervisor in a timely manner.
Perform various tasks as needed or requested by management.
Continually acquire, develop and refine skills as a claim professional
REFERENCES - AVAILABLE UPON REQUEST
STRONG ATTRIBUTES
Extensive knowledge of CPT& HCPCS codes, Medicaid Fee Schedule, Medical Terminology
Strong Knowledge base on Stop Loss, DRG’s, IPPS, Contract language, Uniform billing CMS 1500 and UB04’s.
Familiar with billing and payment guidelines Medicare & Medicaid reimbursement
Quality focused
Strong customer services orientation
Articulate and clear speaking tone
Able to work independently and under pressure with great
Organization skills
Proficient in MS Office, Microsoft Excel, PowerPoint, Internet
Software knowledge: Facets, EMR, iCP, Toolbox, PEGA, XCELYS, CAPSTONE, AVAILITY, LAWSON, Prism, IDX, CARS, Microsoft Excel, MS Word, PowerPoint, Outlook, Webstrat, IDT, Cosmos. And GPS Resolution, E-fax, Printer copier, scanner.
Always wearing a smile and positive attitude.
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