Case Management Medical Assistant

Louisa Howard

Location: Murrieta, CA *****

Skills:

Billing & collections

Knowledge of payer regulations

Appeals Process and submissions

HMO, PPO, EPO, POS knowledge

Durable medical equipment

Case Management

medical terminology

Clinical Review

Insurance verification & benefits

Good verbal and written communication

Customer service

Utilization – Authorization submissions

provider relations

Systems worked: Emdeon, Brightree, Adobe, Oracle, My Unity, CPR+ and Citrix remote, Virtual Health, AWS Connect phone support, Microsoft Teams and Zoom

Education:

High School Graduate Diploma

San Gorgonio High School, Highland California

Training:

Billing and Collections (Quadra Med Inc.)

(Company PAID/sponsored selective advancement training and company certification)

Medical Assistant (ROP) Regional Occupational Program

(Graduate / Medical Assistant Certificate).

Medical Insurance Billing (ROP) Regional Occupational Program

(Graduate / Medical Insurance Billing Certificate).

Work Experience:

Centene Corporation - Tempe, AZ July 2023 – July 2025

Case Manager

Taking inbound calls, from members I assisted in supporting Case Management, by listening to the members needs. And assigning to the proper ques for different risk levels of care.

Also assisted member with utilizing their benefit, by helping to obtain meal benefits, gluco meters, scales and Blood pressure cuff. Connecting members with the community assistance, for other assistance needed.

Referred for Case Management for help with behavioral health and in-home support.

Sierra Winds Retirement community - Peoria, AZ March 2022 – May 2022

Medical Biller (Temporary assignment)

Billing for on monthly routine, Private pay billing for Health center long term.

Billing for Medicare part A and B skilled nursing.

Billing for Lab, pharmacy, xray and therapy charges and Room and Board.

Attended morning briefing to go over admits, treatments and discharges.

System worked, MyUnity, Box, Excel, Windows and Outlook. Customer service with the residents to pay their bills and apply to their accounts.

Soleo Health - Pharmaceutical Strategies – Tempe, AZ Jan 2022 – March 2022

Intake Coordinator (Temporary assignment):

Intake Coordinator for infusion. Verify benefits for infusion and relaying to the patient the understanding of their responsibility.

Noting into the patients accounts, for reference of acknowledgement they fully understand, they may have a responsibility after their insurance pays. System used CPR+, Excel, Windows, Outlook.

Great Elm Healthcare – Mesa, AZ June 2020 – Dec 2021

Denial and Appeal Specialist

Daily routine to rebill rejected claims, investigate reasons, and rebill.

Respond to emails from patients about their bills; take payments and apply to their accounts.

Follow up on high-dollar accounts and utilize portals for medical record submissions when requested by insurance.

Review EOBs for denials and prepare Appeal submissions. Frequently reverify benefits due to denials, obtain authorizations, and submit for retro auth. Identify trends and present solutions to Supervisor.

Handled member grievances and appeals, ensuring timely documentation, investigation, and resolution in compliance with regulatory requirements.

Managed 3rd party insurance billing and collections for CPAP, BiPAP, and ventilators, ensuring patient compliance with machine usage.

Knowledge of DME and related regulations.

Proficient in Brightree, Emdeon, Excel, Adobe, Word, Outlook, and Microsoft Teams for remote collaboration.

Dexcom Inc – San Diego, CA July 2009 – July 2019

Reimbursement and Appeals specialist:

Knowledge of CGM (continuous glucose monitors), their importance for type 1 diabetics, how each part functions, and how the device monitors glucose.

Daily routine included correcting and rebilling rejected claims, ensuring a valid Letter of Medical Necessity was on file.

Followed up on EOBs and denials, requested medical records, reviewed clinicals for medical criteria, and submitted appeals and retro authorizations when required.

Worked with major insurances such as BCBSIL, CareFirst, Kaiser, and Humana, with knowledge of the Blue Card rule.

Provided customer service to patients and worked with insurance companies to secure CGM approvals, including peer-to-peer reviews and supporting patient grievances and appeals when prior authorization was not possible.

Collaborated with team members by sharing knowledge, assisting with quality control prior to billing, verifying benefits, and determining CGM coverage. Set up payment plans for patients paying out of pocket.

Created a custom Appeal letter that successfully explained CGM unit calculations, resulting in approval of several thousand dollars in denied claims.

Contributed to writing the Mission Statement for Dexcom.

Systems used: Oracle, Emdeon, Excel, Adobe, Outlook, and Windows.

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