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Pim Coordinator - Provider Data Management Analyst Resume

5.00 Rating

Long Beach, CA

OBJECTIVE:

To obtain employment in a medical office and/or health insurance setting where I can maximize my Insurance Verification, Administrative Assistant, organizational and communication skills and make a positive contribution to the organization.

PROFESSIONAL EXPERIENCE

Confidential, Long Beach, CA

PIM Coordinator - Provider Data Management Analyst

Responsibilities:

  • Responsible for gathering, coordinating, and processing of data from the provider network for entry into the Provider Information Management System (QNXT)
  • Ensures accurate provider contracts are correctly configured, affiliated and applied with appropriate demographical information.
  • Accurately interprets claims data and enter into the system in such a way that all data is correct and claims adjudication is optimized
  • Determine claims processing errors in relation to provider system data and correct or route accordingly to appropriate department for corrections.
  • Train current staff and new hires as necessary.
  • Audit loaded provider records for quality and financial accuracy and provide documented feedback.

Confidential, Angeles, CA

Confidential - Krystal Mays

Responsibilities:

  • Responsible for contacting healthcare provider offices to schedule field medical coders, medical record technicians and other resources for various medical chart reviews.
  • Assisted in the full range of provider outreach and service interactions within Confidential, including end-to-end provider scheduling and call quality
  • Support incoming calls from Confidential medical coders, medical record technicians, and provider offices.
  • Responsible for preparing, sending, and receiving correspondence externally and internally
  • Coordinates travel requirements for Confidential Field (travel) medical coders and medical records technicians.
  • Maintains effective and collaborative internal relationships with all key functional areas.
  • Daily reporting of project productivity.
  • Reconciles scheduling data.
  • Daily reporting of project productivity and performs special assignments as required

Quality Assurance Administrative Assistant

Confidential

Responsibilities:

  • Provided administrative support to the Quality Assurance Managers and Vice President of Education and Consulting Services.
  • Assisted Quality Assurance team with various tasks regarding quality reports.
  • Created tracking and reporting processes for team.

Confidential - Sergio Carmona

Responsibilities:

  • Primarily responsible for assisting and providing instruction to low income qualified individuals enrolling into state funded assistant programs.
  • Responsible for continuous contact with member during their recertification process to see that renewal/recertification process is completed.
  • Assists participants with all questions regarding completing application and recertification process.
  • Evaluate and determine eligibility for state programs and actively research and stay informed on all state regulations and laws in regards to recertification forms and processes.
  • Acting as a liaison between the state to ensure member continuation in state affiliated programs.

Insurance Verification Specialist

Confidential

Responsibilities:

  • Responsible for verifying, obtaining and logging patient benefits and prior authorizations.
  • Coordinating with insurance plan and doctors office to obtain prior authorization.
  • Verifies primary and secondary insurance coverage for patients; makes written and/or verbal inquiries to payers to verify insurance status and prior authorization status.
  • Obtains and facilitates all letter of medical necessity (LMN) necessary
  • Verifies and logs patient’s co-pay with Payer.
  • Contacts patients, physicians and other health care providers to obtain necessary information to complete a thorough insurance investigation. This includes patient eligibility, how drug is covered, co-pay, deductible, and OOP max. Benefits and prior authorization requirements.
  • Identify situations in which a patient may need financial assistance and reach out to patient to help them obtain assistance.
  • Coordinate with companies offering financial assistance, patient and physician to obtain assistance in an expedited manner. (ex: Chronic Disease Fund, LLS)
  • Manage/process all insurance changes related to current patients enrolled in the BioScrip program.
  • Logs all calls made/received into the system.

STNA and Assistant Activities Director

Confidential

Responsibilities:

  • Change, feed and bathe residents; attending to other personal and grooming needs such as combing hair, trimming nails, brushing teeth, passing bed-pans and helping residents to the bathroom
  • Turn and position bed patients according to turning schedules.
  • Assisting patients, physicians and pharmacies in: drug coverage pre-certification requirements and status claims concerns
  • rder and shipment concerns
  • Prescription Status
  • Identifying situations that require a pharmacist.
  • Understanding emotions through caller tone and words and correctly de-escalating situations and applying proper resolution.
  • Enrolled new members into Medicare Prescription Drug Plan
  • Understanding Medicare Program, providing education to callers regarding Medicare prescription drug plans and processing enrollments into plans while following proper Medicare guidelines.

Customer Service Consultant

Confidential

Responsibilities:

  • Handles telephone and written correspondence from members and physicians.
  • Explains customer/member specific plan of health and pharmacy benefits along with member's responsibilities in accordance with contracted arrangement
  • Copay/ Coinsurance
  • Pre-certification requirements
  • Referral status
  • Claim Status
  • Coordination of Benefits
  • Confirmed for patients and physicians status and requirements of pre-certification approval.
  • Documents and tracks all member contacts, events, and outcomes via appropriate systems.
  • Reviews claims cost payments in order to respond to all requests for reconsiderations or appeal.
  • Assisted members in determining correct coordination of benefit between primary and secondary insurances. Accessed information from a variety of systems and references including contracting and network system.
  • Enrolled new members into health and prescription plans.
  • Processed Health Insurance Claims
  • Skilled in ICD-9 and CPT coding, medical terminology, Medicare practices, COB determination

Customer Service

Confidential

Responsibilities:

  • Processing inbound electronic faxes
  • Contacting providers to confirm prescriptions.
  • Inbound call center environment assisting customers with contact lens orders, returns shipping inquiries billing information.

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