Experience

Independent Health

• United States
• Insurance
• 700 & Above Employee

• Pharmacy Government Programs Quality Assurance Coordinator

  • Sep 2016 - Present

  • Manage and report the daily audit of the Pharmacy Help Desk • Monitor trend reporting for the Pharmacy Help Desk • Ensuring the accuracy of paid Medicare pharmacy claims • Daily audit of pharmacy prior authorization denials • Co-Manage and report Magellan approval and denial correspondence • Manage the completion of the Long Term Institutionalized Report • Completing Transition letter accuracy at 100% • Extensive knowledge of the Pharmacy Help Desk policies and… Show more • Manage and report the daily audit of the Pharmacy Help Desk • Monitor trend reporting for the Pharmacy Help Desk • Ensuring the accuracy of paid Medicare pharmacy claims • Daily audit of pharmacy prior authorization denials • Co-Manage and report Magellan approval and denial correspondence • Manage the completion of the Long Term Institutionalized Report • Completing Transition letter accuracy at 100% • Extensive knowledge of the Pharmacy Help Desk policies and procedures • Identified corrections in the Medicare Help Desk Standard Operation Procedures • Extensive knowledge of the Pharmacy Prior Authorization policies and procedures • Successfully completed the Management Fundamentals Program as the first in Independent Health history • Successfully completed the Career Pathways Program in 2015 • Extensive knowledge of Commercial Benefits, Medicare, State Products, Coordination of Benefits, Claims Adjudication, CPT, ICD-9, ICD-10, Worker’s Compensation and No Fault • Certified as a SharePoint Site Owner • Maintain the privacy and security for all members • Consistently deliver the “Red Shirt Treatment” and living the Core Values of Independent Health

• Quality Assurance Claims Auditor

  • Apr 2013 - Sep 2016

  • Manage the Document Processing quality assurance review for Operations, including Mail Preparation and Medicare • Successfully identified more than $1,945,872.00 in incorrect payments in 2016 • Manage and report daily quality audit of System Quality Assurance in FormWorks at 100% • Initiated the update of Mail Preparation’s Standard Operating Procedures • Identified corrections in the Physician Standard Operation Procedures • Coordinate the 86 Audit Project each… Show more • Manage the Document Processing quality assurance review for Operations, including Mail Preparation and Medicare • Successfully identified more than $1,945,872.00 in incorrect payments in 2016 • Manage and report daily quality audit of System Quality Assurance in FormWorks at 100% • Initiated the update of Mail Preparation’s Standard Operating Procedures • Identified corrections in the Physician Standard Operation Procedures • Coordinate the 86 Audit Project each week • Co-manage the Model Audit Review • Co-manage our Quality Assurance SharePoint site • Successful in meeting or exceeding department goals including 99% of new claims paid in 30 days, 98% of new claims adjudicated in 14 days and 9 or less average days to adjudication • Complete monthly Outstanding Issues Report accurately and timely • Successfully completed the Management Fundamentals Program as the first in Independent Health history • Successfully completed the Career Pathways Program in 2015 • Successfully complete Medicare application audits at 100% each month • Extensive knowledge of Commercial Benefits, State Products, Coordination of Benefits, Claims Adjudication, CPT, ICD-9, ICD-10, Worker’s Compensation and No Fault • Maintain the privacy and security for all members • Consistently deliver the “Red Shirt Treatment” and living the Core Values of Independent Health

• Membership Operations/State Products

  • May 2011 - Apr 2013

  • Ensured integrity for Medisource and Family Heath Plus eligible members • Monitored error reports from our monthly Primary and Secondary Rosters • Performance Metrics were all met by the end of 2012 completing an average of 394 Service Requests a month in less than 1 day. Macess data entry (manually) on average completed 354 documents per month at an average hourly rate of 30 documents per hour • Re-wrote the Medisource and Family Health Plus Manuals with the training… Show more • Ensured integrity for Medisource and Family Heath Plus eligible members • Monitored error reports from our monthly Primary and Secondary Rosters • Performance Metrics were all met by the end of 2012 completing an average of 394 Service Requests a month in less than 1 day. Macess data entry (manually) on average completed 354 documents per month at an average hourly rate of 30 documents per hour • Re-wrote the Medisource and Family Health Plus Manuals with the training department • Auto assigned Primary Care Providers to Medisource and Family Health Plus members that did not choose their own in the 30 day time period allotted • Communicated with various departments responding to Siebel Service Requests • Processed daily newborn information • Completed terminations of Child Health Plus members • Frequent communication directly with Erie and Niagara County Department of Social Services to resolve discrepancies • Supported all other Operations Departments as needed

• Servicing Representative

  • Feb 2010 - May 2011

  • Provided exceptional customer service and consistently met or exceeded monthly quality metrics • Educated members on benefits, eligibility, claims, Explanation of Benefits and authorizations • Followed up with member call backs and requests in a timely manner • Performed quality review of demographic changes and Primary Care Provider updates • Updated members with procedure and policy changes • Managed Fulfillment Bucket in sending out correspondence • Performed scanning… Show more • Provided exceptional customer service and consistently met or exceeded monthly quality metrics • Educated members on benefits, eligibility, claims, Explanation of Benefits and authorizations • Followed up with member call backs and requests in a timely manner • Performed quality review of demographic changes and Primary Care Provider updates • Updated members with procedure and policy changes • Managed Fulfillment Bucket in sending out correspondence • Performed scanning and data entry for Fulfillment department regarding deceased members returned mail



RR Donnelley

• United States
• Advertising Services
• 700 & Above Employee

• Order Processor/Customer Service

  • May 2007 - Jan 2010

  • Managed the processing of business form orders and Rx Pads accurately and timely • Successfully managed customer complaints and issues timely and effectively with resolution • Handled all client and customer requests accurately and timely • Managed set up and supervised all website profiles for Tax Form clients • Managed the production of sales orders for Bed Bath & Beyond • Managed the maintenance of Rx Pads and Farmers Insurance agent profiles and photos • Provided… Show more • Managed the processing of business form orders and Rx Pads accurately and timely • Successfully managed customer complaints and issues timely and effectively with resolution • Handled all client and customer requests accurately and timely • Managed set up and supervised all website profiles for Tax Form clients • Managed the production of sales orders for Bed Bath & Beyond • Managed the maintenance of Rx Pads and Farmers Insurance agent profiles and photos • Provided assistance and support for all other departments when needed Show less • Managed the processing of business form orders and Rx Pads accurately and timely • Successfully managed customer complaints and issues timely and effectively with resolution • Handled all client and customer requests accurately and timely • Managed set up and supervised all website profiles for Tax Form clients • Managed the production of sales orders for Bed Bath & Beyond • Managed the maintenance of Rx Pads and Farmers Insurance agent profiles and photos • Provided… Show more • Managed the processing of business form orders and Rx Pads accurately and timely • Successfully managed customer complaints and issues timely and effectively with resolution • Handled all client and customer requests accurately and timely • Managed set up and supervised all website profiles for Tax Form clients • Managed the production of sales orders for Bed Bath & Beyond • Managed the maintenance of Rx Pads and Farmers Insurance agent profiles and photos • Provided assistance and support for all other departments when needed Show less



KeyBank Commercial

• Financial Services
• 700 & Above Employee

• Sales and Service Professional/Telesales

  • Feb 2004 - Jan 2007

  • Provided customer service and sales to new and existing clients • Client retention and enhancing customer relationships • Sales representative • Processed applications for all products • Mentor and Training assistant with New Hires • Member of the “Change Management Team;” responsible for providing positive reinforcement to co-workers regarding changes in the workplace and bringing any questions or concerns to management • Provided customer service and sales to new and existing clients • Client retention and enhancing customer relationships • Sales representative • Processed applications for all products • Mentor and Training assistant with New Hires • Member of the “Change Management Team;” responsible for providing positive reinforcement to co-workers regarding changes in the workplace and bringing any questions or concerns to management