Prior Authorization, Appeals, Benefit Verification, Customer Service
Resume:
PAMELA ANDRES
Po Box **** Discovery Bay California 94505 •
*********@****.***
Dedicated, compassionate Health Care Benefits Appeals, Prior Authorization and Customer Service Professional. Extensive experience in Bio Tech patient assistance / reimbursement, reimbursement consulting, prior authorization completion/appeals instruction/follow through, patient case management, customer service, client relations, human resources, administration and program management. Reliable Professional Caregiver with over ten years of experience working with private patients burdened with mobility issues, mental faculty conditions and various other ailments. HCA ID: 751-***-****
AREAS OF EXPERTISE
• Utilize exceptional judgment and command of the latest healthcare insurance, client relations, program administration, human resources, and financial management methodologies to add value to any organization.
• Demonstrated ability to deliver unparalleled client service, improve processes, analyze complex case issues, and negotiate accordingly, while simultaneously attaining major company performance goals.
• Skilled at customizing and delivering presentations and insurance/product information to effectively communicate with diverse clients and insurance companies at all levels.
• Tenacious, quick-thinking problem solver with the ability to correlate diverse, incomplete or contradictory information to produce rapid solutions.
• Outstanding communicator and negotiator, adept at working with cross-functional insurance groups to secure favorable claims that exceed expectations.
• Compassionate, loyal, dedicated professional caregiver who enjoys spending time with people as well as helping them live day to day as best as they can.
PROFESSIONAL EXPERIENCE
At Home Compassionate Care L.L.C. - Discovery Bay, CA CEO-COO-CFO/ Senior Caregiver - PCA, HCA, Dementia/Alzheimer’s Care, 07/2018-Present
• Developed and operate my in home non medical care business At Home Compassionate Care L.L.C.
• CPR Certified
• A/R - A/P
• Provide reliable trustworthy companionship
• Cook and prepare meals for same day as well as cook and freeze meals for future consumption
• Run errands
• Drive patient to and from appointments - sit in on medical appointments if requested keeping HIPPA laws in mind
• Schedule and keep all daily appointments on calendar
• Take pets to appointments
• Bath and medicate patient’s animals
Continued…
PAMELA ANDRES • Page 2
• Provide light housekeeping
• Medication administration/Medication Reminders
• Reported changes and updates to patient’s designated family member(s) Self Employed - Mobile Maven Signing Services
California Notary Public, California Notary Signing Agent, 06/18/2016 - 06/18/2020
• Travel to borrower's homes or office to complete loan documents for real estate, refinancing
• Perform duties properly and ethically
• Maintain proper procedures, files and regulations
• Safeguarding of borrowers' private financial information
• Getting loan package back to lender in a timely manner HomeLife Senior Care
Professional Senior Caregiver - PCA, HCA 10/2017-07/2018
• Assist with all ADLs
Interim Health Care- Jackson, CA
Companion Caregiver - PCA, Family Care, Dementia/Alzheimer’s Care, 12/2016-5/2017
• Assist with all ADLs
Vistiting Angels- Cameron Park, CA
Companion Caregiver - PCA, Family Care, Dementia/Alzheimer’s Care, 10/2016-4/2017
• Assist with all ADLs
SELF EMPLOYED - Antioch, CA
Companion Caregiver - PCA, Family Care, Dementia/Alzheimer’s Care, 2014-2016 Private patient care
• Assist with all ADLs
GENENTECH – San Francisco, CA
Senior Reimbursement Specialist, 2009 to 2014
Advanced to senior-level role with responsibility for helping patients and healthcare providers navigate insurance coverage and understand benefits related to prescribed therapies, facilitating efficient access to required medica- tions. Provided leadership and direction to a 10-member team; trained and mentored newly hired staff. Served as vital liaison and resource for health care providers, providing patient health benefit information, prior authorization and referral documentation, and assistance with denied claims and appeal process. Consulted with payers via tele- phone, fax, and online systems to obtain benefit / coverage information and documentation. Provided sensitive pa- tient information to internal and external customers while maintaining strict compliance with HIPPA laws. Prepared PAMELA ANDRES • Page 3
and presented annual SWOT reports to upper management. Coordinated with field reimbursement managers and district managers through 18-state region, facilitating efficient handling of payer issues. Tracked payer trends and generated weekly reports.
• Developed a benefit investigation work sheet comprising all questions a representative must ask a payer while conducting benefit verification.
• Authored and implemented a standardized script for payer calls to improve efficiency and accuracy.
• Hand-selected from a large team to serve as representative for major meetings in Las Vegas and Orlando.
• Created procedures for managing HMO plans and administrators that saved time and boost productivity.
• Led monthly team meetings to motivate and inspire staff while instilling a focus on quality, efficiency, and compliance.
• Assumed leadership role in manager’s absence with accountability for escalating team issues to management, partnering with senior leadership on critical decisions, and overseeing team quality and productivity.
• Played a key role in a pilot program that combined the roles of case manager and field reimbursement man- ager to improve speed and accessibility of information between cases managers and health care offices. GENENTECH – San Francisco, CA
Reimbursement Specialist, 2007 to 2009
Provided assistance to patients and physicians, submitted medical documentation for prior authorization, appeals, and pre-determinations. Promptly followed up on patient cases, providing regular updates on pending cases until resolution. Conducted in-depth research into unpaid claims for prior dates of services and identified steps necessary for claim payment. Processed and documented patient, insurance, and provider information.
• Awarded #1 in productivity across the United States for number of benefit investigations completed within one quarter.
• Worked closely with leadership team to reorganization regional responsibilities of reimbursement specialists, leading to improve customer service for clients throughout the country. LASH GROUP, INC. – San Bruno, CA
Assistant Manager – Operations, 2006 to 2007
Repeatedly promoted through positions of increased scope and accountability during four-year tenure with this pharmaceutical/biotech consulting company. Reviewed daily operations and produced reports for clients, team members, and senior/executive level management, addressing productivity and quality assurance metrics to ensure highest levels of customer service. Conducted random case audits, handled escalated calls, and monitored customer service lines to meet and exceed specified targets. Provided comprehensive training to new and existing employees. Liaised with IT department to identify and resolve database/system issues.
• Received award for exemplary performance; consistently met and exceeded specified performance and project targets; received rapid promotion.
• Developed strong team which resulted in increased revenue and lower operating margin.
• Developed and implemented new program processes and related documentation/flow charts. LASH GROUP, INC. – San Bruno, CA
Senior/Reimbursement Counselor, 2004 to 2006
Conducted monthly research on underinsured foundations and communicated detailed information on application processes instructions, approval guidelines and timeframes back to management, team members, patients and physicians offices. Coordinated with health insurance companies to gather accurate patient benefit information. Assisted patients and physicians by obtaining prior authorizations and assisting with insurance appeals process until resolution, including coding and billing assistance for specific drugs.
• Provided training and advice to team members, patients, physicians, nurses, and sales representatives regard- ing program-specific drug assistance guidelines and criteria
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PAMELA ANDRES • Page 4
Additional experience as a Patient Case Coordinator with Lash Group, Inc. in San Bruno, CA, as a Freight Ana- lyst for Nurserymen’s Exchange, Inc. in Half Moon Bay, CA, as a H.V.C. Revenue Retention Representative / Customer Outreach Representative for AT&T Wireless in San Francisco, CA, an Office Manager / Underwriter with Auto Insurance Specialists Bay Area, Inc. in Foster City, CA, and as a Customer Service Manager with Abraham and Associates Services, Inc., San Jose, CA. PROFESSIONAL DEVELOPMENT
Trained for COVID-19 care, Certificates in CPR, Senior Care Auditing, Personal Care Assisting, Special Needs, Alzheimer's and Dementia Care, Family Caregiver through Certified Care.Licensed Notary and Signing Agent in California, How to Manage Your Manager, Essential Skills of Leadership Supervision Series, Customer Service Excellence, Customer Obsession, Overcoming Objections, Medicare Reform Technical Skills: Salesforce CRM, Windows 10, Mac OS, Unix,, Patient Plus, Siebel, Word, Outlook, PowerPoint, Google Docs, WP 5.1-6.0, Excel, Lotus Notes, FSC Insurance Rating System, MercuSoft, Starfish, CBIS, Mosaix, Macrocell, 10-key, Oracle Orders Entry System, AP, A/R, Data Entry, Scheduling, Inventory Control
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