TONYA BELL-PRINCE

Mobile: 704-***-****

adznzm@r.postjobfree.com

https://www.linkedin.com/in/tonya-bell-prince-55381836

Charlotte, North Carolina

SUMMARY OF QUALIFICATIONS

15+ years’ experience in the healthcare industry. Supervised 12 or more employees. Trained, supervised, and evaluated staff. Quality Analyst. Claims Processing. Healthcare Ethics and Compliance. Extensive knowledge of HCPCS, CPT and ICD-10 coding. Claims. Food and Drug Administration Health Regulations. Statistical Analysis. Prior Authorizations. Appeals. Claims Management. Case Management. Medicare/Medicaid Experience. Knowledge of Federal Regulations. Regulatory Affairs. Pharmacy Benefit Management. Conflict resolution. Task management.

EMPLOYMENT HISTORY

Government Program Eligibility Representative II May, 2020-

North Carolina Department of Commerce

Communicate with claimants via phone or email.

Interview claimants to file unemployment insurance claims and update claims as needed.

Determine if appeal claims are valid.

Provide all necessary information to claimants and prepare claims for adjudication.

Complete all work items within the claim where appropriate.

Investigate claims for fraud.

Work special projects for claims processing.

Healthcare Compliance Consultant-Contractor September, 2019-

Clinic For Women

Ensure compliance with contract provisions with various agencies to include applicable State and Federal Laws.

Consult with appropriate personnel to serve as a compliance resource for various processes.

Conduct periodic assessments to ensure compliance with contractual and regulatory requirements and submissions.

Analyze and advise regarding health policies and procedures to ensure federal and state regulatory compliance for an acute care setting.

Claims Examiner II October, 2018-August, 2019

Lincoln Financial Group

Determine covered medical insurance losses by studying provisions of policy or certificate.

Establish proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.

Resolve medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.

Senior Reimbursement Consultant July, 2013-October, 2018

AmerisourceBergen/Lash Group

Collect and review all patient insurance benefit information authorized by the Standard Operating Procedures of the program.

Complete and submit prior authorizations, formulary exceptions and appeals.

Assist medical staff by completing and submitting all necessary insurance forms and applications.

Complete and submit appropriate insurance forms and electronic claims to process the claims in a timely manner as required by all third-party payers.

Communicate effectively to payers and/or claims clearinghouse to ensure accurate and timely electronically filed claims.

Process any necessary insurance/patient correspondence.

Maintain confidentiality of all information of patient account status and the financial affairs of clinic/corporation

Analyze quality and performance.

Healthcare Reimbursement Consultant.

Quality Analyst.

Review faxes before being processed for outbound.

Claims Management.

Initiate Commercial Co-Pay Cards.

Mentor.

Customer Service Representative March, 2009-July, 2013

Iqor

Answer inbound calls.

Schedule gas turn-ons and cut offs at customer requests.

Assist customers to prevent gas service interruption.

Provide great customer service to Peoples Gas and North Shore Gas customers.

Schedule payment arrangements.

Resolve customer concerns via one-call resolution.

Accept payments over the phone.

Pharmacy Assistant Manager July, 2005-October, 2008

Wal-Mart Pharmacy

Supervise 12 or more employees.

Train, supervise, and evaluate staff, including pharmacy technicians and cashiers.

Schedule staff

Provide patient counseling concerning prescription and over-the-counter medications.

Practice drug utilization reviews concerning drug to drug and drug to disease interactions.

File prescription insurance claims.

Assist in maintaining proper drug inventory within pharmacy budget limits.

Assist in day-to-day pharmacy operations within state and federal compliance and guidelines.

EDUCATION

Regulatory Affairs Certificate-Pharmaceutical April, 2023

Online Certificate Program

Masters of Jurisprudence in Healthcare Law August, 2016

Loyola University Chicago

Masters of Business Administration Concentrating in Health Services Administration August, 2011

Strayer University

Bachelor of Science Pharmacy May, 1992

University of North Carolina at Chapel Hill

Bachelor of Science Biology May, 1989

Saint Augustine’s University

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