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Skills

  • Supervision
  • Project management
  • Relationship development
  • Problem resolution
  • Denial rate reduction strategies
  • Data analysis and reporting
  • Organization
  • Team building
  • Effective team collaboration
  • Medical coding expertise (CPT, ICD)

Work Experiences

  • Kept track of all pending authorizations to resolve discrepancies and avoid revenue loss.
  • Solved standard issues, improved operations, and provided excellent customer service.
  • Corrected client appeal applications.
  • Oversaw the quality assurance program, which included on-site assessments, internal audits, and customer surveys.
  • Collaborated with cross-functional teams.
  • Decreased appeal escalation rate by 16%.
  • Converted 24% of denied claims into approved benefits.
  • Achieved Excellence Award.
  • Achieved additional $3 revenue recovery.
  • Built strong relationships with insurance adjusters.

Summaries

  • Hardworking Appeals Specialist with 11 years of telecommuting experience meeting customer needs.
  • Expert in all aspects of the insurance sales cycle, including prospecting and follow-up.
  • Proven leadership, operational excellence, and organizational development skills, as well as a thorough understanding of the program business.
  • Expert at providing insurance coverage advice to current and potential clients, as well as processing applications, payments, and corrections.
  • Within Miscellaneous, senior Appeals Specialist and outstanding performer in stakeholder engagement and team leadership.
  • Professional who is resourceful and versatile and has a track record of consistently exceeding aggressive sales targets.
  • Achieved 37% success in favorable settlements.
  • Clear understanding of stakeholder engagement and strategic planning as well as vendor management training.
  • Collaborated with key departments.
  • Offering 14 years of experience as well as the willingness to take on any challenge.

Accomplishments

  • Documented and analyzed over 5 appeals per month using Salesforce, maintaining a consistent accuracy rating of 37%.
  • Led the overhaul of the appeals monitoring process, resulting in a reduction of open appeals from 7 to 5.
  • Trained staff on key insurance appeals policies, improving claim accuracy by 39% and reducing rework time.
  • Successfully appealed 6 denied claims, securing approval and recovering over $5 in lost reimbursements for the company.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Reduced appeal escalation rate by 31% through targeted negotiation strategies and relationship-building with external stakeholders.
  • Analyzed and resolved 10 complex appeals cases monthly, achieving a resolution rate of 35%.
  • Served as the primary liaison between healthcare providers and payers, facilitating successful claim negotiations in 83% of cases.
  • Integrated new data analytics tools to identify high-risk claim denials, reducing appeals processing time by 2 hours per case.
  • Implemented a quality assurance program that increased overall team review accuracy by 59%, reducing errors in appeals processing.

Affiliations

  • Committee Member, Policy Review Panel on Appeals and Denials 2022
  • Association of Information Technology Professionals
  • Association for Supply Chain Management (APICS)
  • Appeals Advocate, Healthcare Legal Forum 2024
  • Jaycees
  • National Association of Case Management (NACM)
  • Rotary International
  • American Association of Medical Auditors (AAMA)
  • Affiliations with State Health Insurance Programs Chicago
  • Freemason

Certifications

  • Certified Medical Reimbursement Specialist (CMRS)
  • Certified Professional Medical Auditor (CPMA)
  • Microsoft Certified Systems Engineer (MCSE)
  • Certified Revenue Cycle Specialist (CRCS) – American Association of Healthcare Administrative Management (AAHAM)
  • SHRM Senior Certified Professional (SHRM-SCP)
  • Certified Medical Auditor (CPMA) by AAPC
  • National Association of Healthcare Access Management (NAHAM) Certification
  • Google Certified Professional Cloud Architect
  • First Aid/CPR Certified
  • Certified Public Accountant (CPA)

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