Experience

Universal Health Care

• United States
• Insurance
• 100 - 200 Employee

• Appeals Team Lead

  • Feb 2012 - Present

  St. Petersburg, Florida Directly responsible for the processing and support for all Medicare and Medicaid member appeals. Provide immediate support to the Appeal team to ensure all cases meet the state and federal requirements. Perform quality management and oversight on a weekly basis. Communicate professionally and productively with internal departments and external regulatory agencies. Participate in ALJ, MAC, and MFH hearings. Compile daily monitoring reporting to the department management. Effectively maintain… Show more Directly responsible for the processing and support for all Medicare and Medicaid member appeals. Provide immediate support to the Appeal team to ensure all cases meet the state and federal requirements. Perform quality management and oversight on a weekly basis. Communicate professionally and productively with internal departments and external regulatory agencies. Participate in ALJ, MAC, and MFH hearings. Compile daily monitoring reporting to the department management. Effectively maintain the department standard of 90% uphold rate at Maximus Federal Services. Assist in the development and delivery of new hire onboard and ongoing training materials. Maintain team standard working instructions for case handling consistency

• Appeals and Grievance Analyst

  • Apr 2011 - Present



Omnicare, a CVS Health company

• United States
• Pharmaceutical Manufacturing
• 700 & Above Employee

• Pharmacy Technician/Intake Coordinator

  • Jan 2011 - Aug 2011

  Tampa/St. Petersburg, Florida Area Received and entered incoming prescription orders into the pharmacy database system efficiently and effective on a daily basis. Offered clarity to physicians and patients with medication status and dosage. Interacted with Medicare and Medicaid insurance carriers and Pharmacy Benefit Managers concerning claim adjudications and billing. Given responsibility to provide C3-C5 emergency approvals and STAT requests



CVS Health

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

• Pharmacy Technician

  • 2010 - Jan 2011

  Tampa/St. Petersburg, Florida Area Assisted patients with new prescriptions, refill, and transferred prescriptions. Pulled keyed in prescriptions from system, retrieved and filled prescription orders. Handled inventory duties, to include: waiting bin maintenance, cycle count, out of stock items. Offered clarity to physicians and patients with medication dosage, drug interactions, and potential side effects of prescription and OTC medications. Maintained accurate patient records, dosing information and directions for use… Show more Assisted patients with new prescriptions, refill, and transferred prescriptions. Pulled keyed in prescriptions from system, retrieved and filled prescription orders. Handled inventory duties, to include: waiting bin maintenance, cycle count, out of stock items. Offered clarity to physicians and patients with medication dosage, drug interactions, and potential side effects of prescription and OTC medications. Maintained accurate patient records, dosing information and directions for use. Interacted with Medicare and Medicaid insurance carriers and Pharmacy Benefit Managers concerning claim adjudications, billing and reimbursement matters. Assisted night pharmacist with all areas of the pharmacy operations. Show less



UnitedHealth Group

• Hospitals and Health Care
• 700 & Above Employee

• Grievance &Appeals Coordinator

  • 2004 - 2009

  Tampa/St. Petersburg, Florida Area Researched and resolved written, verbal, and complex or multi-issue provider complaints submitted by consumers, physicians/providers and Department of Insurance. Reviewed, researched, investigated, negotiated and resolved all types of member appeals and grievances for both commercial and Medicare including Medicare Part D. Communicated with internal departments and external regulatory agencies. Completed all data entry requirements for appeals and grievances cases into company database… Show more Researched and resolved written, verbal, and complex or multi-issue provider complaints submitted by consumers, physicians/providers and Department of Insurance. Reviewed, researched, investigated, negotiated and resolved all types of member appeals and grievances for both commercial and Medicare including Medicare Part D. Communicated with internal departments and external regulatory agencies. Completed all data entry requirements for appeals and grievances cases into company database. Assisted in training peers in the introduction of the Medicare Part D system Show less



Town and Country Medical

• Medical secretary

  • 2003 - 2004

  Tampa/St. Petersburg, Florida Area Responsible for the physicians appointment scheduling. Accountable for checking patients in and out, collected patient information during intake and collected payments during check out. Pulled charts for scheduled patients for the following business day. Filed and updated charts at the end of each day. In charge of maintaining office supplies including disposing of any expired medications.



Diabetic Supplies USA

• Customer Service

  • 2002 - 2003

  St. Petersburg, Florida Responsible for inbound and outbound customer calls regarding diabetic devices, respiratory and colostomy products. Educated customer on the use of the items and offered insurance coverage rules or patient assistance programs. Researched existing patient files to ensure quality assurance on all demographic and supply order directions and dosage. Prepared claim forms for billing department



Aetna, a CVS Health Company

• United States
• Wellness and Fitness Services
• 700 & Above Employee

• Customer services/ Claims processor

  • Mar 1998 - 2002

  Tampa/St. Petersburg, Florida Area Received inbound calls from members and providers regarding benefits and claim status. Researched, analyzed and resolved all claim issues for patients and providers. Responsible for adjudicating submitted claims from members and providers. Assisted other processors on claim processing steps and procedures.