Debra Manoochehri
Summary
Highly motivated, high-energy professional with over 23 years of customer service, with 13 of those years in the medical industry, combines strong organizational and communication skills with the ability to work in an extremely fast-paced environment. Exceptional customer service skills with excellent problem-solving skills; creative and resourceful in resolution. Both flexible and versatile, a well-rounded performer committed to continued excellence.
Overview
16
16
years of professional experience
Work History
SIU INVESTIGATOR ANALYST
AETNA
11.2022 - 08.2023
- Conducts investigations of known or suspected acts of healthcare fraud, waste, and abuse
- Communicates with federal, state, and local law enforcement agencies as appropriate in matters pertaining to the prosecution of specific healthcare fraud cases
- Investigates to prevent payment of fraudulent, abusive, or otherwise improperly billed claims submitted by providers, members, and others
- Facilitates the recovery of company and customer monetary losses
- Provides input regarding controls for preventing or monitoring fraud related issues within the business units
- Delivers educational programs designed to promote deterrence and detection of fraud and minimize losses to the company
- Documented findings and prepared detailed reports.
- Prepared detailed investigation reports for management teams and legal departments, facilitating effective decision-making processes.
- Maintained thorough documentation of all investigative actions taken, ensuring compliance with company policies and legal requirements.
MEDICAL CLAIMS ANALYST CCR
AETNA WAH
02.2022 - 11.2022
- Responsible for post - service claim review to determine if specific service can be reimbursed to providers and members
- Start the CCR process with the claim submission to CCR with a complete review of the claim and claim history
- Review providers and members claims to determine if they meet CCR review requirements
- Follow applicable workflows, templates, and legal and compliance requirements to provide a complete picture of what is required review to the CCR clinicians and medical directors
- Organizes and prioritizes work to help meet regulatory and CCR claim turn round times
- Determines coverage, verifies eligibility, benefits, identifies discrepancies, and applies all Medical Claim Management policies and procedures.
INFORMATION & REFERRAL SPECIALIST
AETNA
09.2020 - 02.2022
- Utilize designated interactions to assess the member's stated and unstated needs, including social determinants of health
- Thoroughly complete member questionnaires, accurately assess member need, and appropriately document results in the member record
- Secure resources to address the member's needs, including connection to community and national resources
- Accurately assess the need for clinical (Nurse RN or Social Worker) intervention and work closely with Engagement Hub Clinical Consultants to serve our members
- Educate members on available services and empower participation
- Assist the member in actively participating with their health care providers and Aetna Care Management teams regarding decisions that impact their health and well-being
- Document all member interaction into the appropriate member record(s)
- Demonstrate empathy for situations faced by our members and their caregivers
- Troubleshoot unavailability of resources, securing support as needed to close member gaps.
QUALITY ESCALATIONS & AUDIT LEAD
AETNA
09.2012 - 02.2020
- Collaborated with Managers and Supervisors providing daily reports of production
- Managed department staff and phone stats to meet monthly goals
- Monitored Quality e-mail box and assigned work accordingly
- Performing supervisor duties in the absent of the manager and supervisor
- Handled escalated supervisor calls and aimed to provide a satisfactory resolution to the caller
- Single point of contact for all Executive Complaints filed against ASRx
- Served as SPOC between ASRx and CVS for end of day closing operations
- Developed a training schedule for new hires
- Drafted the Quality Escalations training manual for new hires
- Approved attendance segments using the SMT Segment Management tool
- Investigated CAT's complaints received via e-mail; researched complaint, reviewed calls, and provided a timeline of events
- Received and answered all Corporate Complaints regarding - complaints filed against Asrx
- Review, analyze, and approve Drug Re-ships
- Monitored Escalations phone queue and reps AUX and available time using the Avaya CMS Supervisor tool
- Avid user of People Safe to check for benefit eligibility, and prescription precertification.
HEALTHCARE QM ANALYST/ SR. QUALITY ANALYST
AETNA
07.2012 - 02.2020
- Handled phone calls, responds to written inquires and handles escalated issues in support of work performed by Aetna Specialty Pharmacy employees
- Answer questions and resolves issues as a single-point-of contact based on phone calls, letters and internet brokers, marketing plan sponsors, members, providers, and Aetna Pharmacy Management
- Liaison for reporting all adverse events as it relates to members medication
- Identify potential services failures which saved the Pharmacy in revenues
- Report to management daily recovery cost from issues that occurs from the exceptions
- Coordinates efforts both internally and across departments to successfully resolve services issues and assistant in the development of process improvements intended to enhance the overall delivery of service
- Collects and verifies data
- First point of contact for all issues that arise at Aetna Specialty Pharmacy, which are associated with any service failures
- Document and tracks all contact, events, and out comes with the client using appropriate systems and processes
- On-call duties after hours support -first line on-call responsibility
- Triage calls to nurse on-call and pharmacist on call as appropriate
- Escalates issue as appropriate through the target system for grievances and appeals
- Replacement Coordinator, reship processing for both supplies and medications.
CLAIMS BENEFITS SPECIALIST
AETNA
02.2008 - 02.2012
- Worked special projects to ensure payments have been properly posted to patients' accounts
- Reviewed patient's accounts to ensure that payment was posted to correct invoice, Rx and Dates of Service
- Analyzes and approved claims
- Obtained information from EOB for accurate posting of co-pay, deductible, co-insurance, and DOS
- Created batches and invoices, viewed on accounts payments
- Posted payments to correct invoices
- Moved on account balances to correct invoice
- Reviewed manual and electronic claims for accuracy
- Claims processing experience
- Experience in production environment
- Data Entry experience
- ACAS claim processing
- Assured departmental and company production rates were met each month
- Increased order production at a representative level from 8 orders per hour to 24 orders per hour.
Education
CERTIFICATION - Medical Coding & Insurance Billing
AMERICAN SCHOOL OF NURSING
01.2008
Bachelor Degree - Criminal Justice
FLORIDA ATLANTIC UNIVERSITY
01.1993
Skills
- Work well under pressure
- Organized
- Fast Learner
- Customer Service Oriented
- Data Analysis
- Claims and Insurance Knowledge
- Critical Thinking Skills
- Self-starter
- Advance organizational and prioritization skills
- Work effectively within a team dynamic
Timeline
SIU INVESTIGATOR ANALYST
AETNA
11.2022 - 08.2023
MEDICAL CLAIMS ANALYST CCR
AETNA WAH
02.2022 - 11.2022
INFORMATION & REFERRAL SPECIALIST
AETNA
09.2020 - 02.2022
QUALITY ESCALATIONS & AUDIT LEAD
AETNA
09.2012 - 02.2020
HEALTHCARE QM ANALYST/ SR. QUALITY ANALYST
AETNA
07.2012 - 02.2020
CLAIMS BENEFITS SPECIALIST
AETNA
02.2008 - 02.2012
CERTIFICATION - Medical Coding & Insurance Billing
AMERICAN SCHOOL OF NURSING
Bachelor Degree - Criminal Justice
FLORIDA ATLANTIC UNIVERSITY