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Bronx, New York, NY, USA
Home Health Residential Aide
June 2013 - May 2014
Successfully provided daily care for resident in a home health setting
• Assisted resident in daily activities to provide maximum care
• Assisted resident in scheduling appointments, obtaining referrals, and escorting resident to and from daily activities
Insurance Specialist/Coder II
October 2008 - May 2013
• Successfully assisted providers and/or patients in verifying eligibility of benefits for submission of claims
• Successfully educated providers on authorization processes to receive maximum claim reimbursement
• Verified Insurance coverage via telephone, online, and through the Electronic Verification System(EVS)
• Analyzed and processed appeals for Medicare Part D Prescription Drug Plan
• Supported doctors, hospitals, and Health Plan in obtaining prior-authorization for pre-services and post services for Medical and Pharmacy services
Appeals and Grievance Analyst
July 2004 - October 2008
• Processed appeals for Quality Improvement Organization, Centers for Medicare and Medicaid services
• Performed necessary claim adjustments as required per the appeal resolution. This includes advanced levels of claims transactions/claim types and coordination of benefits.
• Analyzed system authorization to ensure accurate data entry with an understanding of Medical Management department's administrative processes and guidelines.
Schaller Anderson of Maryland
February 2002 - July 2004
• Process Incoming grievances and appeals for (Member, Provider, Hospitals)
• Process Claim Payment requests and generate request for Explanation of Payment/Benefits due to coding discrepancies and/or improper usage of codes.
• Provide customer support via inbound and outbound telephone calling to answer question from (Members, Provider, or Vendors)
• Prepare weekly reports for the Medical Management team
Switchboard Operator, Administrative Assistant, and Appeals Coordinator
April 2001 - January 2002
Unit Clerk Health Assistant, Cashier, Switchboard Operator
Humana Group Health Plan
March 1989 - April 2001
Qualifications & Certifications
Academy of Professional Coders
CGNA Petersburg School of Practical Nursing
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