Nadirah Donaldson

Healthcare Claims Adjuster

adwjx3@r.postjobfree.com • 609-***-****

LinkedIn URL • Trenton, NJ

Highly analytical and results-driven professional with vast experience in all facets of claims processing and adjudication, medical billing, team leadership, and reconciliation/HMO capitation across diverse healthcare and insurance sectors. Proven success in identifying invalid claims and implementing necessary actions through utilization of claim adjudication process. Track record of facilitating successful completion of claims processes and overseeing processing of prior authorizations, while ensuring achievement of service-level satisfaction. Well versed in documenting and managing various adverse reaction reports, performing analysis, resolving patient/healthcare provider complaints, and providing appropriate advice to drive major improvements in customer experience and operational efficiencies. Meticulous team leader possessing exquisite communication skills with proven background of fostering and maintaining strong relationships with clients, colleagues, and all level of management to achieve prescribed business goals.

Areas of Expertise

Claim Processing & Authorization

Reporting & Documentation

Medical Billing & Payment

Claim Investigation

HIPAA

Complex Problem Resolution

Insurance Statements

Microsoft Office Suite

Claim Adjudication

Legal Documents

Customer Service Optimization

Team Training & Leadership

Relationship Management

Performance Analysis

Workers Compensation

Professional Experience

14 Street Medical Arts – New York, NY March 2022- Present

Medical Records / Workers Comp Specialist/ Prior Authorization Specialist

Prior Authorization Specialist

Obtain Prior Authorization for testing ordered by multispecialty doctors including PCP, OBGY, Gastroenterologist, Neurologist, Pain Management, Orthopedic, Cardiology etc.; Responsible for requesting Prior Auth/ Pre-Cert from insurance carriers to assure all diagnostic testing including MRI, CT, MRA and Ultrasounds are preauthorized for billing prior to testing with clinicals and encounters, point of contact for conducting provider peer to peer for denials using Athenahealth and eMedNY systems.

Medical Records Specialist

Maintain patient medical records specifically focusing on Release of Information (ROI). The recipient of requests for medical documentation/results in a database from insurance companies, providers, patients, and attorneys. Facilitate the creation of invoices of payment for release under New York State compliance, received payments and process payments for release of information. The liaison for insurance companies, providers, patients, attorneys, SSI, disability, responsible for handling documents from all areas including physician practices, hospital releases and corporate compliance. Answer incoming calls from patients, pharmacies, DME supplier, medical facilities, health insurance companies etc. Assist doctors with clinicals, lab and imaging testing results to coordinate follow up, specialty and preventive care visits.

Workers Comp Specialist

Responsible obtaining pre-certification from a patient’s insurance company - Commercial carriers, Motor Vehicle and Workers' Compensation- in accordance with their policy to enable the patient to receive treatment or durable medical equipment. Process and submit pre-certification request through the NY Government portal to receive pre-certification from the patient’s insurance company to ensure coverage for the patient’s treatment. Appeal pre-certification denials based on the rules and regulations of each carrier. Reviews scheduling system so pre-certifications are verifications are accurate and completed prior to patient appointment/procedure to avoid billing/payment errors. ensures that pre-certification updates (e.g., approvals, denials, and appeals) are input daily into practice management system, tracks patient’s pre-certifications using spreadsheets and practice management software. Notifies scheduling, front desk, and treating providers when patient’s allotted visits are due to expire. Uses customer service principles and techniques to deal with insurance companies and third-party payers calmly and pleasantly.

Anticipates when pre-certification will be needed to prevent lapse in patient coverage/care.

Coordinates with the providers, business office manager and front desk coordinators to obtain additional necessary information needed to complete the pre-certification.

Athenahealth, CoverMyMeds, NY.Gov portal

Communicates as needed with Medical Providers, business office manager and other staff about any patient concerns/issues related to pre-certifications.

Prior Authorization

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AmeriHealth – Philadelphia, PA (temp) Jan.2019 - Jan. 2022

Pharmacy Invalid Claims Specialist

Researched and recognized invalid claims and provided corrective actions by utilizing claims adjudication procedure with key emphasis on accuracy and detail. Audit and process medical bills within statutory timeframes, by following medical coding guidelines and department policies and procedures, verify correct payee and provider information and ensure that all bills that meet audit criteria are routed immediately for audit purposes. Communicate with claims personnel relating to complex issues regarding authorizations, pre-certification, and compensability. Apply state fee schedules when appropriate, review and respond to MSA QC (Quality Control) issues including current billing questions, retroactive billing concerns, stops and reimbursement requests. Research and respond by telephone/email to provider inquiries regarding billing issues in a timely manner, oversaw coursing of all claims to suitable/relevant billing provider. Steered end-to-end completion of allocated claims to achieve service-level agreement satisfaction. Participated and completed all required training/cross training sessions. Ensured timely completion of all projects allocated by supervisor.

●Successfully gained strong knowledge and expertise in claim processing from different territories.

●Administered and re-routed all rejected claims with invalid/incomplete provider information.

IMS Health – Warren, NJ March 2017 – Jan. 2019

Pharmacy Program Support

Performed a wide range of key activities such as answering inbound calls from various pharmacies, troubleshooting, resolving problems, and delivering first-call resolutions for clients and patients. Served as mentor to CSR team members, while providing outstanding leadership and training to achieve prescribed team goals. Authenticated insurance by utilizing OIG validations to ensure patient eligibility for various programs. Oversaw processing of prior authorizations received via prior authorization helpline. Supervised processing of adverse reaction reports and manufacturer-specific complaints.

●Drove major improvement in inbound caller experience, supported supervisor functions on demand, and trained on OBRA 90, while recognizing various training opportunities and executing necessary solutions.

●Created and delivered reports, conducted robust analysis, and proposed appropriate suggestions to facilitate major improvements in customer experience and operational capabilities.

PharmScript Pharmacy – Somerset, NJ May 2017 - Dec. 2017

Pharmacy Facility Biller (Evening)

Upheld a wide range of responsibilities such as recording and monitoring census from various beneficiary facilities to ensure accurate billing to Medicare, Medicaid, and private insurance companies. Created precise patient invoices within facility, while completing all end of month billing processes. Communicated and engaged with multiple organizations to track status of Medicaid-eligible residents/personnel. Provided outstanding support and instructions to various personnel, including patients, billing staff members, and insurance companies. Designed and maintained accurate month-end reports through utilization of MS Excel spreadsheets.

●Manage and facilitate pharmacy billing of Nursing Homes, Rehabilitation Centers and Assisting Living Facilities

●Ensured compliance with OBRA 90 and OBRA 93 regulations, while performing a wide range of key tasks such as reviewing and sustaining medical billing, claim records, settlements, and medical insurance statements for facilities.

●Led processing/submission of reimbursement requests to Medicare, Medicaid, and private insurance companies.

●Recognized and resolved various complaints related to patient and physician billings.

Horizon NJ Health – West Trenton, NJ July 2011 – Dec 2016

Case Management (Care Specialist Il)

Oversaw completion of initial assessments, evaluation of member-specific needs, and referral of complicated cases to registered nurses (RN). Delivered exceptional care management services to mild cases, while maintaining documentation of member outreach with key emphasis on accuracy. Facilitated outstanding delivery and authorization of services as per requirements. Provided outstanding support to members in advocacy for various government initiatives and rights. Received and managed MLTSS customer inquiries via different mediums, including telephone, fax, mail, email, online, and social media platforms. Commenced multiple investigative procedures in accordance with overall nature of question such as claim, member information, benefits, enrollment, and appeals. Performed accurate documentation of MLTSS customer inquiries and corrective actions taken in compliance with department quality guidelines to ensure proper follow up on unresolved problems. Communicated with higher management regarding trending information on consistent and regular basis. Visited multiple MLTSS customer sites to provide excellent problem resolution on complex issues and to ensure achievement of set MLTSS customer service levels.

[i]Led coaching and education of various personnel and staff members regarding preventative medical care, while supervising multiple care procedures, access issues as well as all horizon BCBSNJ programs available.

●Motivated/empowered members, eliminated obstacles, and facilitated access to superior medical care along with adherence to medical instructions and services, while referring various members to community-based programs.

●Established and sustained diverse network of recent community programs and resources.

●Provided optimal customer services experience in compliance with quality and manufacturing regulations.

Additional Experience

Customer Service Associate I, Merrill Lynch – Pennington, NJ

Education & Credentials

Computer Engineering and Criminal Justice (2017 - Present)

Bucks County Community College (AAS) – Newtown, PA

Rowan College Burlington County (AAS) – Mount Laurel NJ

Surgical Tech (2000-2002)

Harrison Career Institute – Delran, NJ

Medical Office Administration (1996-1997)

Cittone Institute – Ramsey, NJ

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