Prior Authorization Data Analyst

SUMMARY OF QUALIFICATIONS

Forward thinking and the initiative to suggest and implement program enhancements and improvements

Strong analytical skills/problem solving and conceptual thinking

Maintains, updates and ensures the accuracy of standard documents, records and inventory

Possess good critical thinking and the ability to think outside the box along with the ability to prioritize and balance multiple task

EDUCATION AND TRAINING

KING’S COLLEGE

Associate Degree in Computer Applications and Programming 2003

Selected Academic Projects:

Developed, implemented Microsoft Excel spreadsheets to calculate business cost and determine trends.

Maintained and analyzed Microsoft Access database used to track inventory

COMPUTER APPLICATIONS:

SAP Software, AS400, EDI, Lotus notes, Microsoft Office: Word, Excel, Access, PowerPoint, Front-Page, Patient Plus EDI system, SharePoint, Theracall database, NICE

PROFESSIONAL EXPERIENCE

AmeriHealth Caritas NC (ObjectWin Technology Staffing) Charlotte, North Carolina 28269

Appeals & Grievances Coordinator March 2023

Communicate updates and status of outstanding member and provider complaints and issues to upper management.

Research and investigate member and or provider appeal and grievance request, including review of denial reasons

Obtain data from multiple systems (FACETS, MACESS, JIVA, Insight) to ensure all documentation needed for appeal is obtained

Collaborate with counterparts as needed to ensure proper handling of the grievance/appeals process

BCBS of NC (Spectraforce Technology Staffing) Charlotte, North Carolina 28269

Senior Claims Professional June 2021 – January 2023

Responsibilities include managing daily work queues, quality of claims processed and final resolution.

Also monitors claim turnaround times to assure all compliance guidelines are met as well as performance guarantees.

Determine suspended claim resolution methods by reviewing benefit eligibility, claims history and other information

Escalate claims requiring specialized resolution to subject matter experts based on department policies and guidelines to ensure the resolution

Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability

HCA Healthcare (Parallon) Charlotte, North Carolina 28273

Insurance Follow-up Representative April 2019 – June 2021

Process and review CPT codes, listed diagnosis and medical insurance accounts to address claim issues and to affect payment and/or bring them to resolution.

Utilizing Epic, OnBase and Passport computer software, research is completed with carriers (Medicare, VA, BCBS, Availity Aetna) portals to view payment/denial remarks on records

Reconcile balances and claim payments between insurance companies and client computer systems.

Utilizing EPIC software to submit and upload electronic medical records to provider portals and complete follow-up calls to ensure claims are processed within payers timely filing limits

Amerisource Bergen Specialty Group (Lash Group) Charlotte, North Carolina 28208

Data Analyst– GSK PAP June 2016 – March 2019

Perform quality assurance activities by reviewing Medicaid/Medicare as well as private insurance records and changes to records to ensure accuracy, completeness and compliance with policies

Conduct assigned monthly quality reviews of electronic medical records and/or patient files through call monitoring NICE application, case files review to determine if processed according to Standard Operating Procedures (SOP)

Provides feedback to quality management team and clients using reports generated via Salesforce CRM program

Lead call monitoring calibration sessions with QA team, department leads, management and clients to ensure consistency of scoring

Provide daily development and coaching with staff members- perform audits, determine training needs, provide performance feedback weekly

Monitor and ensure daily production goals and quality of work are being met through audits of accounts per day following a set schedule

Senior Reimbursement Counselor – Lemtrada September 2014 – June 2016

Collects and reviews all patient Medicaid/Medicare benefit information, to the degree authorized by the SOP of the program

Main point of contact and regionalized point of contact for Area Managers as well as field team members

Handled a high volume of inbound calls resolving product and service complaint by clarifying customer issue

Leader of weekly sales call meetings; providing updates via Microsoft Spreadsheets as well through Patient Plus EDI system

Responsible for initiating and following up on Healthcare insurance prior authorization and pre-determinations by transmissions of patient data via Patient Plus EDI system

Provided secure electronic data interchange between healthcare institutions, care providers, and patients, allowing for more secure and efficient data processing, including healthcare claims processing, prior authorization and pre-determinations

Distribution Coordinator – Lemtrada June 2014- September 2014

Main point of contact for SPPs (specialty pharmacies) & buy and bill entities

Ensure the current status is updated on benefits that the Specialty pharmacies may need to prior to shipping patient’s benefits

Confirm all Risk Evaluation Management Strategy forms have been completed prior to creating shipments

Processed and coordinated shipments via Patient Plus EDI system sending real time inventory reports to clients

Patient Case Coordinator – Sunovion/Suboxone September 2012 – June 2014

Provides advanced services to patients, providers and caregivers, including but not limited to: billing and coding support, claims assistance, tracking and submission, prior authorization assistance and tracking, coordination of benefits, advanced alternative coverage research and reporting adverse events as directed

Managed a high volume of inbound patient calls (40-60 daily) used to determine patient insurance benefit and eligibility information

Researching and processing insurance claims, including resolving any claim denials and underpayments of claims

Establishing self as regional expert on payer trends and reporting any reimbursement trends

Data Intake Specialist - (Sanofi) April 2012- September 2012

Collaborated with site and patient coordinators on enrollment applications received via Patient Plus data exchange system

Responsible for accurate database entry into Patient Plus System (15-20 documents per hour)

Benefit Verification Specialist (Medimmune) August 2011- April 2012

Verifying patient insurance benefit information.

Triages cases with missing information to appropriate program associate.

Verifies patient specific benefits and precisely documents specifics for various payer plans including patient coverage, cost share, and access/provider options.

Identifying any coverage restrictions and details on how to expedite patient access.

Documenting and initiating prior authorization process and claims appeals.

Reporting any reimbursement trends or delays to management.

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