Daniel Sutton
Irwin,PA
Overview
19
19
years of professional experience
Work History
Reimbursement Specialist/ Case Manager
PainTeq
02.2023 - 06.2025
- Submitted prior authorizations to all health insurance carriers for pre-service approvals.
- Managed a large daily case load for multiple physician offices across the United States.
- Completed patient chart reviews to ensure patients meet all medical necessity requirements per the health plans guidelines.
- Reviewed radiology reports for any findings that may disqualify patients from receiving the surgical implant.
- Assisted sales reps and physician offices with all aspects of medical reimbursement.
- Created both internal and external appeals for all pre-service denials.
- Monitored medical claims and assisted physician offices and facilities with any denied claims.
- Educated physician offices and patients on the approval process for a surgical implant that is considered to be experimental/investigational.
- Completed weekly and monthly patient reports to ensure all cases were meeting compliance.
Insurance Collections Specialist
Zoll Medical Corporation
06.2022 - 01.2023
- Write appeals to insurance payers on behalf of the company and patients to have denied claims overturned.
- Work multiple claim reports to ensure all timely guidelines are being met and that all appeals are submitted timely and correctly.
- Resubmission of insurance claims after identifying rejection reason or that the initial submission was not received by the correct by payer.
- Resolve all credit balances and write offs by submitting refunds and adjustments.
- Monitor and manage assigned high dollar payer accounts.
- Submit corrected claims to payor after making necessary edits on HCFA 1500 Claim forms.
Quality Supervisor of Prior Authorization & Correspondence Team.
United Healthcare
10.2019 - 10.2020
- Performed all regular supervisory functions: new hire on boarding, Time & attendance reporting, monthly & annual reviews, merit increases, Corrective action plans, and career path guidance.
- Managed multiple client projects through to completion, ensuring all new client products launched successfully and that all target were reached on time.
- Managed all client meetings to review upcoming RX benefit changes and review any state and/or federal requirements. Review all target dates with client managers to discuss any potential risks or obstacles and communicate job status. Advise of any required signature’s that may be needed.
- Performed audits on all prior authorizations, approvals, denials and letter templates to ensure they were meeting all contract agreements, and were within state/federal compliance regulations.
- Implemented quality control process to monitor and improve departments quality of work, increase productivity and improve team deficiencies. (This reduced departments failure rate by 32%.)
- Managed all aspects of quality for 21 team members
- Performed 84 quality audit evaluations monthly. Prepared and presented all quality reports to Vice President and Director.
- Measured work against established metrics and expectations to ensure effective processes and efficient production.
- Managed all aspects of document control.
Sr. Clinical Coordinator-Team Lead (Remote Employee)
United Healthcare
04.2014 - 08.2019
- Resolved all escalated health inquiries from medical directors, state health plans and clients
- Acted as a liaison with staff, medical directors, internal and external clients, by developing & maintaining effective working relationships.
- Assisted Health plans with claim processing to ensure payments were timely and accurate.
- Assisted providers with appeals
- Managed all department documents such as training materials, flow charts, Job aids, sop guidelines and also updated departments Share point Site.
- Worked daily, monthly and quarterly department reports to help improve claim processing, speed, and quality.
- Managed daily inventory to ensure all state and federal compliance regulations/deadlines were being met as per Medicaid and Medicare guidelines.
Clinical Coordinator (Remote employee)
United Healthcare
07.2011 - 04.2014
- Entered prior authorizations for hospital admissions, acute services, and durable medical equipment.
- Answered over 100 incoming provider calls a day.
- Provided detailed knowledge of Medicaid and Medicare prior authorization guidelines for several different lines of business.
Server
Kings Family Restaurant
04.2009 - 07.2011
- Performed all tasks associated with serving the needs of customers.
Dispatcher
Dish Network
09.2008 - 04.2009
- Tracked multiple technicians during their daily routes to ensure efficiency and schedule adherence.
Clinical Specialist
CVS/Caremark
04.2007 - 09.2008
- Worked collaboratively with patients, clinical staff, and medical review board to obtain prior authorizations for high-cost medications.
- Such as cancer medications, infusion treatments, and HIV medications.
- Entered and maintained medication prior authorizations in the clinical data base.
- Responsible for gathering patient clinical and diagnosis information to start the prior authorization process.
Customer Service Representative
CVS/Caremark
11.2006 - 04.2007
- Responded to a high volume of incoming customer escalation calls.
- Answered any questions members had about their prescription benefits.
- Refilled prescription medication requests over the phone.
Education
Bachelor of Science - Healthcare Management
University of Phoenix
Tempe, AZ09.2013
Skills
- Appeals handling
- HCPCS coding
- HIPAA compliance
- ICD-10 coding
- Microsoft office
- Insurance verification
- Denial management
- ICD 9 coding
- Medicaid
- Eligibility verification
- Administrative writing
- Medicare
- Commercial insurance
- Teamwork and collaboration
- Problem-solving
- Time management
- Attention to detail
- Problem-solving abilities
- Multitasking Abilities
- Excellent communication
- Organizational skills
- Team collaboration
- Effective communication
- Relationship building
- Deadline oriented
- Reporting skills
- Task prioritization
- Quality control
- Administrative support
- Microsoft Office Suite
- Data analysis
- Quality assurance management
- Claims processing
- Healthcare industry
- Policy evaluation
- Managed care
Timeline
Reimbursement Specialist/ Case Manager
PainTeq
02.2023 - 06.2025
Insurance Collections Specialist
Zoll Medical Corporation
06.2022 - 01.2023
Quality Supervisor of Prior Authorization & Correspondence Team.
United Healthcare
10.2019 - 10.2020
Sr. Clinical Coordinator-Team Lead (Remote Employee)
United Healthcare
04.2014 - 08.2019
Clinical Coordinator (Remote employee)
United Healthcare
07.2011 - 04.2014
Server
Kings Family Restaurant
04.2009 - 07.2011
Dispatcher
Dish Network
09.2008 - 04.2009
Clinical Specialist
CVS/Caremark
04.2007 - 09.2008
Customer Service Representative
CVS/Caremark
11.2006 - 04.2007
Bachelor of Science - Healthcare Management
University of Phoenix