Reimbursement Specialist
Resume:
TYRA
WOODS
**********@*****.***
**** ****** **** ****, ******, NC 27302
WWW: Bold Profile
SUMMARY
Qualified Senior Reimbursement Specialist with expertise in policy research and customer service. Offering years of experience in analyzing coverage and securing collection for claims. Excellent written and verbal communication skills.
EXPERIENCE
REVER CARE COORDINATOR 11/2024 to 03/2025
Mercalis - Morrisville, North Carolina
Verified patient prescription benefits, including medical and pharmacy coverage, to ensure accurate billing and reimbursement.
Investigated authorization requirements for specialty medications and any ancillary supplies, collaborating with healthcare providers and insurance companies as necessary.
Determines patient eligibility for copay card assistance programs based on program criteria and facilitates enrollment as appropriate.
Knowledgeable in performing all benefit investigation functions.
Provides thorough, accurate, and timely responses to requests.
Educated clients on available resources and services within their communities.
SR. REIMBURSEMENT SPECIALIST 05/2023 to 05/2024
UBC - 680 Century Point, FL
Served as point of contact for prescribers, patients and pharmacies.
Conducted benefit investigations by verifying insurance benefits for patient and physician's office per request.
Submitted prior authorizations as required by payer.
Arranged conference calls with payors for patient appeals and medication overrides.
Worked with Medicaid and Medicare patients, verifying benefits and eligibility for patient assistance programs.
Enter and maintain data as required in client database and patient files.
Utilize the client database to monitor outstanding items on each client case file. Ensure files were complete so the team can determine the current status.
Participate in conference calls as needed with Client management and physician offices regarding status of cases and status of alternative funding.
Provide coordination shipment of product and therapy initiation with pharmacy and patient.
Researched complex reimbursement questions from providers regarding policy interpretation and application.
Educated patients and others regarding program requirements, and facilitate authorizations.
Communicated regularly with external parties, such as vendors and insurance companies, concerning various aspects of the organization's reimbursement program.
Adhere to quality and production standards, and comply with all applicable company and state regulations.
Reviewed, analyzed, and processed provider reimbursement claims for accuracy and compliance with all applicable regulations.
SITE ACTIVATION COORDINATOR 09/2021 to 01/2022
Radiant Systems - South Plainfield, NJ
Provided administrative support for site activation activities.
Supported the development of the critical path for site activation within assigned projects.
Assist with technical and administrative support for projects in collaboration with internal departments and team members.
Work directly with site to obtain documents related to site selection.
Maintain knowledge of and understand SOP's client SOP's/directives and current regulatory guidelines.
Assisted the project team with the preparation of regulatory compliance review packages.
Ensured trial status information relating to activities are accurately maintained in the database and current at all times.
Provided support as needed to coordinate with internal departments, to ensure site startup activities within the site activation critical path are aligned.
CUSTOMER SERVICE AGENT 02/2021 to 09/2021
eTeam Inc - Somerset, NJ
Quickly and efficiently respond to incoming calls identified how to assist.
Document calls in appropriate tracking systems, and handle/escalate calls per established procedures.
Process Claimant applications of various complexities, and follow the programs specifications to determine their eligibility. Place follow up calls and respond to enquiries from claimants.
Delivered fast, friendly and knowledgeable service for routine questions and service complaints.
Set up and activated claimant accounts.
Fielded individuals complaints and queries, fast-tracking them for problem resolution.
De-escalated problematic customer concerns, maintaining calm, friendly demeanor.
Upheld strict quality control policies and procedures during customer interactions.
Documented conversations with customers to track requests, problems and solutions.Managed high-volume of inbound and outbound customer calls.Educated claimants on how to navigate company systems and work within established frameworks to obtain desired services.Asked probing questions to determine service needs and accurately input information into electronic systems.
Assisted customers with inquiries regarding products and services through phone, email, and chat.
Investigated and solved routine, complex and long-standing claimant issues each day.
CUSTOMER SERVICE REPRESENTATIVE 07/2019 to 01/2020
Med-EL - Durham, NC
Served as the primary contact for customers including patients/family members, medical providers (hospital, implant centers, research centers and surgeons, audiologists, educators regarding product needs.
Worked with patients and clinics by answering product and service questions.
Processed orders, prepared correspondences and fulfill customer needs to ensure excellent service standards and maintain high customer satisfaction.
Accepted special projects and assignments as business requires.
Assisted others Med-EL team members in achieving company goals.
Strategize with customers by listening, interpreting their needs, and advising on solutions.
Communicated with customers thru email within one business day.
Collaborated with all internal staff members including Reimbursement, Accounting, Product Control, Order fulfillment and sales team on a regular basis to help maintain account relationships.
Informed customers about billing procedures, processed payments.
Escalated customer concerns, store issues, and inventory requirements to supervisors.
Tracked emails, phone call interactions per day for auditing, reporting, and training purposes.
REIMBURSEMENT SPECIALIST 07/2018 to 03/2019
Aerotek - Morrisville, NC
Worked with the Jansen CarePath Program verifying patient health insurance eligibility for specialty medications such as Remicade, Simponi, Tremfya, Stelara.
Responsible for obtaining and creating prior authorizations and triage cases for patient's to receive medications through commercial medical and pharmacy plans .
Determine program eligibility by conducting Verification of Benefits for providers.
Gained accurate documentation of payor information and patient status.
Identified potential adverse events and transferred to clinical program member.
Acted as single point of contact for assigned group of prescribers.
Worked with traditional Medicare Part A/B, Medicare Advantage, MAPD an supplement policies to verify benefits for eligibility.
Maintained community-based customer relationship management (CRM) database by entering data for referrals and appointments.
Performed a wide range of pharmacy operations with strong commitment to accuracy, efficiency, and service quality.
Observed strict confidentiality and safeguarded all patient-related information.
Drafted documents based on payer guidelines and submitted to the necessary parties.
Applied health insurance expertise and exemplary customer service skills to attain correct verification of benefits.
REIMBURSEMENT SPECIALIST 11/2017 to 01/2018
Remedy Temp Services - Morrisville, NC
Verified patient benefits for all assigned patients within program required timeframes.
Notified appropriate stakeholders of verified and corrected information.
Complete accurate entry of payor information to ensure timely payment and avoid delay in patient therapy.
Daily communicated with payers and physician offices regarding program status and financial responsibility.
Perform duties necessary to facilitate payment from third party payers.
Processed a designated amount of new patients daily by accurately inputting information in the system.
Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
EDUCATION AND TRAINING
Southern Alamance High School
High School Diploma
COMPUTER SKILLS
Microsoft Office, Outlook. Excel, PowerPoint, Teams Knowledge of Computer Database: Webfocus, Medco, IDX, Rightfax, AS400, Teams Elite, Misys, SAP, Medco, Navision, CRM, MaxMC
Hyland Onbase, Groupwise, Sharepoints, NC Tracks, Maestro Care, ARMC Healthlink, UCSW, Security Connect, Centricity, Salesforce, UNC Carelink, Cover My Meds, CRM,Skype, AWS, ServiceNow, Beacon,Select, CTMS, Nitro Pro, Clarity, DocuSign, ADP, Neocase, EV5, Cisco Finesse, Netsecure, E-time, Benefit Solver, Cosmos Medicaid, Medicare, AARP, Part C medical plans. Tricare,Workday, Zendesk, Kronos, Slack, Cisco Jabber, Tea, E-Verify, HR Central, The Point, PeopleCare,Payroll, Change Health, Opus Health, Five- Nine, Clearview, Citrix Workspace, JDE, ADP, Paychex, Epic, Valet, Change Health, Opus, JDE, Citrix Workspace, Kronos, Cover My Meds,
Medicare Part A&B, Part D, Medcare Advantage. Commercial Insurance.
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