Experience

Devoted Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Medicare Product Ops Manager

  • Mar 2023 - Present

• Medicare Product Associate

  • Apr 2021 - Mar 2023



AmeriHealth Caritas

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Medicare Product Manager

  • Apr 2020 - Apr 2021

  I make sure we have a competitive benefit package for our valued Medicare members through managing the end-to-end product development cycle across AmeriHealth Caritas Medicare VIP Plans. I oversee the implementation of new First Tier, Downstream, and Related entities vendors, guide the implementation and assist in the oversight of vendors once they’ve been onboarded, from operational issues to audits.

• Medicare Appeals & Grievances Team Lead

  • May 2019 - Apr 2020

  As a team lead in the Appeals & Grievances Department, I assist in the day to day operations of our department, acting as an initial point of contact for all matters relating to Appeals & Grievances. I coach and lead team members, and assist in developing individual improvement plans when needed. I've developed and lead training sessions for not only Appeals and Grievance team members, but presented training courses at all-staff meetings for multiple lines of business. While taking on… Show more As a team lead in the Appeals & Grievances Department, I assist in the day to day operations of our department, acting as an initial point of contact for all matters relating to Appeals & Grievances. I coach and lead team members, and assist in developing individual improvement plans when needed. I've developed and lead training sessions for not only Appeals and Grievance team members, but presented training courses at all-staff meetings for multiple lines of business. While taking on these supervising duties, I also maintain some responsibilities for specific complaint and grievance investigations. This includes taking the lead on any and all complaints received directly via CMS' Complaint Tracking Module, and resolving beneficiary complaints in anywhere from two to thirty days. I also act as the liaison and subject matter expert for trends involving supplemental benefits. These trends directly impact our members, so I'm proud to have a direct role in making sure things are running as expected. I achieve this by monitoring any eligibility discrepancies, making sure contracts are up to date, and coordinating monthly meetings between AmeriHealth Caritas and our supplemental benefit providers.

• Medicare Senior Investigation Specialist

  • May 2015 - May 2019

  At AmeriHealth Caritas, I investigate grievances and complaints issued by D-SNP and MMP plan members and participating providers for four lines of business. Grievances range from concerns regarding benefits coverages to concerns about the quality of care they are receiving from their doctor; it's my job to obtain as much information as possible from the member an all parties involved. I maintain strict deadlines in order to complete the investigation and resolve the grievances according to… Show more At AmeriHealth Caritas, I investigate grievances and complaints issued by D-SNP and MMP plan members and participating providers for four lines of business. Grievances range from concerns regarding benefits coverages to concerns about the quality of care they are receiving from their doctor; it's my job to obtain as much information as possible from the member an all parties involved. I maintain strict deadlines in order to complete the investigation and resolve the grievances according to Medicare guidelines. As a seasoned team member, I also train new team members and evaluate their work for quality assurance. In addition to daily operations, I assist in the creation and distribution of quarterly reports to monitor grievance trends.



Cotiviti

• United States
• IT Services and IT Consulting
• 700 & Above Employee

• Junior Auditor

  • Sep 2014 - May 2015

  At Connolly, I identified overpayments issued by medical insurance providers. I analyzed claim data obtained through multiple software programs, including those that are Microsoft Access based. Through contract investigation, I identified additional recovery opportunities. I maintained direct contact with hospital billing departments to clarify any questions about our auditing process. At Connolly, I identified overpayments issued by medical insurance providers. I analyzed claim data obtained through multiple software programs, including those that are Microsoft Access based. Through contract investigation, I identified additional recovery opportunities. I maintained direct contact with hospital billing departments to clarify any questions about our auditing process.



Executive Health Resources

• Appeals Management Supervisor

  • May 2013 - May 2014

  As an Appeals Management Supervisor at EHR, I monitored a team of 10+ employees in their submission of Medicare appeals for medical necessity and coding reviews. In addition to submitting Medicare appeals to RACs, MACs, QIOs, and OMHA, I oversaw the scheduling of calls between EHR's clinicians and client physicians for case clarification. My team also monitored incoming information requests from RACs, MACs, QICs, and OMHA. Additionally, I conducted quarterly performance based reviews… Show more As an Appeals Management Supervisor at EHR, I monitored a team of 10+ employees in their submission of Medicare appeals for medical necessity and coding reviews. In addition to submitting Medicare appeals to RACs, MACs, QIOs, and OMHA, I oversaw the scheduling of calls between EHR's clinicians and client physicians for case clarification. My team also monitored incoming information requests from RACs, MACs, QICs, and OMHA. Additionally, I conducted quarterly performance based reviews for employees and assisted in the creation of training and internal processes documentation.

• Appeals Management Coordinator III

  • Jul 2012 - May 2013

  • Organized physician written letters and CMS documentation for submission to RACs, MACs, QICs, and OMHA • Verified denial dates for Medicare appeals, ensuring appeals were submitted timely • Conducted trainings for processing Medicare reviews • Performed daily Quality Assurance checks on outgoing Medicare Appeals

• Case Entry Specialist in Government Appeals

  • Nov 2011 - Jul 2012

  • Reviewing, editing, and verifying medical charts and Medicare government appeal documents • Entering patient demographic information into EHR’s database for physician review • Maintaining complete Health Insurance Portability and Accountability Act (HIPAA) compliance • Assisting in the training of new hires

• Level II Clinical Support Team Administrative Assistant

  • Sep 2010 - Nov 2011

  • Accessed client Electronic Medical Records • Guided team members daily with detailed instruction on a case-by-case basis • Trained new hires in company protocol for case processing • Problem solved to resolve team conflicts • Contacted hospital case managers for case clarification • Monitored case creation for timeliness and accuracy



Greater Media Philadelphia

• MMaRmy Promotions Staff

  • Jun 2011 - Dec 2012

  • Lead sponsored station events in the Philadelphia area • Promoted events through the use of social media websites • Photographed events to demonstrate advertising effectiveness for the sales team

• Production and Social Media Intern for The Preston and Steve Show on 93.3 WMMR

  • Jan 2010 - Aug 2011

  • Created and monitored the Preston & Steve Girls Facebook page • Pitched ideas to clients for the creation of promotional videos for WMMR.com • Photographed and edited images using Adobe Photoshop • Researched and created guest information sheets for guest interviews • Edited and posted podcasts in VoxPro • Pulled air checks for sponsors and sales team • Screened phone calls for contests, on-air comments, and station inquiries • Transcribed and logged shows



MediciGlobal Inc., Patient Recruitment & Retention

• King of Prussia, PA

• Account Managment Intern

  • Nov 2008 - Dec 2009

  • Researched outreach opportunities for potential clinical study participants and reported findings • Contributed to the creation, editing, and distribution of internal and client press releases • Created and proofread physician and patient marketing materials • Developed and researched social media outlets for direct-to-patient marketing • Monitored recruitment and retention metrics for international studies sites • Researched outreach opportunities for potential clinical study participants and reported findings • Contributed to the creation, editing, and distribution of internal and client press releases • Created and proofread physician and patient marketing materials • Developed and researched social media outlets for direct-to-patient marketing • Monitored recruitment and retention metrics for international studies sites