Ashly Frazier

Case Manager is responsible for performing daily responsibilities including but no limited to:

•Inbound/Outbound call taking and outreach to external/internal entities (e.g, Health Care Providers (HCP's), Patients current/prospective,

Specialty Pharmacies, Outpatient Facilities, Field Service Representatives, Health Plan/ Insurance Companies and/or Partners etc.)

to initiate or complete program enrollment.

• Review and verify benefits for each patient in efforts to assist with copay, prior authorization/appeals, COB, UM and reimbursement issues.

• Inputting data into CRM platform and supporting systems to initiate enrollment of new and existing patients.

• Initiating benefit verification by reviewing patient and health plan data, and identifying any unresolved or missing information to complete

verification, and initiating any subsequent task(s) and/or actions when warranted.

• Analyze and compile data/trends to assist and support with ongoing efforts and initiatives.

• Following Standard Operating Procedures (SOP's)and exhibiting the ability to learn by utilizing internal resources and collaborative web based platforms.

• Understanding and adhering to all governmental and company regulation(s)and/or policies(s).

• Maintaining positive rapport through active listening and effective communication to ensure a positive caller experience.

BSWH Specialist is responsible for resolving routine inquiries and assigned

task including but not limited to:

• Ensuring appropriate communication is made between Patients and

Providers.

• Coordinating care and communication between BSWH System Facilities and

its patients and providers. This may involve handling patient feedback,

Technical Support, Troubleshooting, Website Navigation, Outbound Follow

up calling and appointment confirmation.

• Responding to inbound inquiries to assist as front-line support for Web

Support, Class scheduling Physician Referral and Provider Location via

Inbound phone or Electronic chat.

• Working collaboratively with clinical staff and other departments by

identifying and escalating priority issues in efforts to ensure all patients needs

are met and resolved.

• Documenting all patient and customer contact information within CRM

system to accurately and timely process various documents to ensure optimal

service.

Performing daily/assigned duties including but not limited to:

• Monitor and administer accounts for current and new patients

• Process patient applications in accordance to set State and Governmental

policies, procedures, and PHI compliances

• Input detailed account information in company's proprietary software and

application(s)

• Contact Insurance Companies/ other 3rd Party Entities via OB Call as

required to verify and obtain accurate benefit information to minimize

rejections and complete claim processing

• Assess and resolve any payer/pharmacy claim(s) issues that may impact

adjudication

• Document and submit any Adverse Event(s) identified per FDA Guidelines

• Provide case updates Rx manufacture field team members via IB/OB phone
call, and/or email communication
• Work together with colleagues, team members and other supporting dept(s).
to ensure account accuracy and timely processing of patient application

Assisting in all facets of daily operation including but not limited to
• Process pharmacy prior authorization request(s) explanation of pharmacy
benefits, eligibility, Rx Billing information, resolving rejected claims, point of
sale adjudication, entering pharmacy overrides for approved medications, and
interpretation on of approved drug formulary to ensure that medication is
dispensed per Managed Care guideline(s). Recommended and counsel
Physicians, Members, Pharmacist, Long Term Facilities, and Hospitals etc. On
utilization management as well, alternative formulary coverage and drug
rules.
• Applying appropriate PA criteria and completing request via phone,
facsimile, and/or web
• Monitoring turn-around time for assigned cases/ plans,
Reviewing/completing prior authorization information received in
preparation of clinical review as well as research/analyze requested
information from internal entities to provide accurate information and
expedited resolutions.
• Adhering to all State/Federal accreditation standards and regulatory
guidelines.
• Knowledgeable in MCO Pharmacy Claims, Medicaid plans, and Anthem
Systems, ICD-9, HCPCS/ and Medical Terminology

Performing daily/assigned duties including but not limited to:
• Start to end processes associated with accuracy of claim data management
and timely adjudication of medical claims
• Researching/Reviewing, and modifying claim data impacting auto
adjudication on claims previously paid and/or overpaid, determining
reason(s) for overpayment per contracted benefits, and other insurance to
obtain required information to complete claim processing
• Identify/addressing issues Analyze claim codes as a part of the risk
adjustment data submission process

Assisting in all facets of daily operation including but not limited to:
• Initiate/process pharmacy prior authorization/appeal requests
• Provide support with front-end clinical reviews including handling/manage
client, member, provider(s) correspondence via inbound/outbound phone call,
facsimile, voicemail, and E-mail
• Respond/escalate any appropriate request from internal/external entities
regarding appeals, implications, and decisions to ensure accuracy and
timeliness
• Troubleshooting of claims and providing an appropriate resolution of any
issues involved: POS Rejects, Rx claim overrides, Clinical approvals/ overrides

Key Responsibilities included:
• Performed clerical duties
• Document Filing
• Data Organization
• Input/Pull travel budget
• Collaborate/ trend and graph data