SUMMARY

• Goal driven, compassionate and accountable professional with over 12 years of relatable hands - on experience in a fast-paced healthcare management environment
• Adaptable administrator accustomed to the integration of new healthcare delivery systems, restructuring of work and an increasingly complex regulatory environment
• Ability to use strong communication skills, organization and problem solving skills and to liaise with various departments, institutions and the public to bring awareness and bring support to the facility

AREAS OF EXPERTISE

• Staff Training and Patient and Family Support
• HIPPA Regulations
• Development
• Time Management
• Grants Management
• Team Coordination
• Medicare A,B & D
• Decision Making and and Leadership
• Medicaid Coverage
• Problem Solving
• Public and Confidential Health
• Policy Implementation
• Community Relations
• Insurance Premium Program
• Healthcare Management
• EDI Claims
• Healthcare Terminology
• Coordination of Benefits

PROFESSIONAL EXPERIENCE

Confidential

Sr. Customer Service Representative

Responsibilities:

• Works directly with sales and clients to provide consultation, documentation or research needed to provide business solutions. Performs quality control functions.
• Develop and sustain a strong Client Relationship by maintaining open communication, monitoring account activity.
• Work directly with IT Project Managers and Business Team Lead to implement new EDI claims processing with newly acquired clients.
• Maintain communication with distribution manager to ensure all EDI updates are processed.
• Is responsible for the general administration of all aspects of the wholesaler chargeback system
• Continually look for areas of improvement in projects, products, processes. Push and sell ideas in a constructive manner to appropriate parties.
• Demonstrate client and Otsuka’s needs are the primary focus by being creative within requirements and environment without being complex.
• Manage customer master file in Oracle for location and price discrepancies.
• Manage incoming contract process including executing contracts in Oracle system.
• Support monthly performance report production; update key metric reports with a final report to Customer Service Manager.
• Accounts Receivable liaison; resolving outstanding accounts receivable problems, including follow up with customer advising of payment options. Provide feedback to sales team on AR metrics as required.
• Answer inbounds customer service calls
• Train new hires

Confidential

Reimbursement Consultant

Responsibilities:

• Provide Tier 2 and Tier 3 support to our clients to ensure reimbursement for products/services.
• Maintain communication with medical directors of large commercial health care providers including not limited to UHC, BCBS, Humana, Aetna, Cigna, Coventry, etc. in order to ensure review of unfavorable reimbursement policies.
• Contact and maintain communication with MCR and MCD to investigate claim denials for our clients seeking reimbursement for products and services rendered.
• Communicate with MCR clearinghouses for investigational purposes to ensure EDI claims were received and processed properly.
• Interpret and analyze EOB’s/MCR and MCD remittances to assist the client with claim investigation pertaining to product reimbursement.
• Familiarity with ICD-9 coding guidelines and the transition to ICD-10 coding guidelines.
• Familiarity with investigation of commercial and CMS websites to obtain information pertaining to new fee schedules and reimbursement policies
• Over-communication with team members to ensure that all projects and follow-up task are completed in a timely manner.
• Familiarity with internal database system to record client interaction and to provide reporting information.
• Compile reports pertaining to reimbursement status and policy investigation status.
• Answer all reimbursement line calls from clients and sales reps requesting assistance with coding and billing.
• Respond to all email inquiries from clients and sales reps in a timely manner to provide a high level of customer service.

Confidential

Health Licensing Specialist

Responsibilities:

• Reviews and approves licensure applications of health professionals in a timely manner in accordance with relevant statues, regulations, and board policy of the Confidential
• Assist in the development and amendment of policy/regulation or guidelines for assigned health boards or task forces including but not limited to Social Media, Expedited and Retired Licensure, Medical Marijuana, Telemedicine, Collaborative Practice, and Certified Professional Midwives. Perform investigative research for best practice policies in other states for the Boards consideration when developing regulations for the District.
• Establishes and/or maintains necessary and helpful communications with individuals and Organizations involved with the regulation of health professionals in the District of Columbia, as well as in other jurisdiction
• Provides administrative support to assigned health licensing boards
• Participates in the development of application forms for licensure applications of health professionals.
• Notifies applicants in a timely manner of application deficiencies and of application closure
• Updates the Confidential 's contracted computer system to accurately reflect the status of applications and licenses.
• Provides timely and professional administrative support to assigned health licensing boards, including, but not limited to, preparing and mailing of meeting agenda; arranging meeting space and necessary equipment; preparing minutes of board meetings; and preparing correspondence as requested by assigned health licensing boards and professional organizations.
• Establishes and/or maintains necessary and helpful communications with individuals and organizations involved in or concerned with the regulation of health professionals in the District of Columbia.
• Attends board meetings as assigned to provide assistance by performing interpretive, administrative and support function as required, including the presentations of organizations involved in or concerned with the regulation of health professionals
• Attends professional/organizational meetings and conferences
• Administers board examinations.
• Arranges for honoraria and other reimbursement forms for board members in accordance with applicable policies.
• Prepares drafts of board newsletters for review by the Executive Director and relevant health licensing board.
• Assists in the orientation of new board members and in arranging and holding conferences, seminars and briefings, which pertains to board activities.
• Communicates to the office superior in a timely fashion on administrative, resource and programmatic issues as appropriate.
• Maintains a pleasant and professional demeanor with the public and co-workers at all times.
• Represents the Confidential and the assigned health professional licensing board when Communicating legal requirements and polices in an accurate and professional manner.

Confidential, Rockville, MD

Financial Services Advisor

Responsibilities:

• Point of contact and lead concerning all matters regarding coordination of benefits, and commercial insurance.
• Responsible for working as a lead to the facility and physicians to protect and advice on private insurance patients within the region.
• Develop an advisory relationship with patients and counsel them regarding insurance issues such as the ramifications of changing coverage, reviewing and applying for additional coverage
• Develop and maintain patient portfolios for periodic review.
• Prepare and deliver weekly reporting on key metrics and benchmarks established by management
• Advanced knowledge of medical terminology as well as knowledge of government and private insurer rules and regulations
• Knowledge of CPT, ICD-9 and HCPCS coding as well as in-depth knowledge of dialysis billing requirements and all pertinent medical business functions.
• Collection of Out-of-Network checks that are sent to patients for dialysis services rendered.
• Collected 96% of all checks that are sent to patients in the Capitol Region.
• Develop and execute re-payment agreements with clients.

Confidential, ROCKVILLE, MD

Safety Net Coordinator

Responsibilities:

• Point of contact and lead concerning all matters regarding the Medicare Part D/Safety Net programs.
• Trained Social Workers and Healthcare professionals on all grant programs available
• Develop, and implement protocol for our new Grants Management System. Notifying social workers of patient status through email responses and mailings while complying to all HIPPA guideline
• Assist pharmacist with verification of patient’s enrollment date and billing process.
• Created and edited position descriptions for the company based on the company standards as it related to organizational structure.
• Developed and implemented strategic goals related to management of the department
• Provided assistance in the development and preparation of various organizational reports and actions
• Reviewed correspondence and documents prepared for the supervisor’s signature or requires his/her coordination.

Confidential, Gaithersburg, md

Program Specialist

Responsibilities:

• Liaised with healthcare team on patient requests on prescription and other needs
• Respond to inquiries regarding third party payment. Research reimbursement cases and relay results to customers. Screen and process patient assistance applications by determining eligibility and making out bound follow up calls as necessary.
• Update database systems on patient enrollment, denials, withdrawals, shipments, and caller request.
• Provided support for member personal changes, updates and application error.
• Work with distributors and manufacturers to request and track product shipment.
• Develop and maintain a great relationship with sales representatives and clients associated with the Cephalon product line (Aqtic, Fosrenol, etc.) as well as responded to emails and voice mail inquires in a timely fashion to meet the needs of the client
• Coordinate in secured coverage for medications and process claims efficiently to help prevent confusion and delay

Confidential, ROCKVILLE, MD

Program Specialist

Responsibilities:

• Liaised with healthcare team on patient requests on prescription and other needs
• Offer most specialty drugs available on the market today, which gives both patients and their doctors a wide range of choices.
• Coordinate in secured coverage for medications and process claims efficiently to help prevent confusion and delay
• Supply patients individualized attention: Before each prescription refill, we call patients to check in and resolve any issues they might have.
• Coordinate the delivery of specialty drugs to multiple locations, including a patient's home or office, select CVS/pharmacy locations, and doctors’ offices. Our shipping processes help ensure that drugs meet industry quality standards when they are delivered
• Liaised within out bound call center conducting investigative calls to subrogate erroneous claims
• Update computer database system on patient enrollment, denials, withdrawals, shipments and caller requests. Work with distributors and manufactures to request and track product shipment.
• Develop and maintain a great relationship with sales representatives and clients associated with the Mirena Reimbursement Hotline as well as responded to emails and voice mail inquires in a timely fashion to meet the needs of the client.