GINA DURAN
Baldwin,NY
Summary
Efficient Reimbursement Specialist with solid background proactively managing claims and preventing insurance issues. Competent in keeping records accurate and current and proactively managing account problems. Excellent customer relations skills combined with analytical approach to handling routine and complex delays.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Field Reimbursement Manager
Johnson & Johnson, Janssen Pharmaceuticals
05.2024 - Current
- Responsible for ensuring patients have access to and are appropriately reimbursed for products or therapies
- Reviewed billing and collections process and determined improvements to streamline workflows.
- Observed strict data confidentiality procedures to protect patients' information.
- Monitored accounts receivables by reviewing payor account listings.
- Held weekly staff meetings and implemented team building exercises, which promoted positive working environment.
- Maintained strong knowledge of medical terminology and procedures.
- Guided office staff on how to effectively complete prior authorization forms and appeals documentation to achieve positive results.
- Prevented delays and claim denials by correcting information prior to submission.
- Delivered timely information to insurance representatives to resolve common and complex issues.
- Employed clinical and billing codes expertise to correct billing inconsistencies.
- Trained department employees in proper billing and accounting procedures.
- Helped minimize escalations by reaching out to clients in advance of expected problems.
- Coordinated with insurance providers to verify customer's policy benefits in relation to claims.
- Built proactive, client-specific edits into system to prevent future denials.
- Followed up on denied and unpaid claims to resolve problems and obtain payments.
- Contributed knowledge to help improve financial management, billing and tracking systems.
- Monitored and documented accounts receivable trends and account-specific profitability.
- Created documents in accordance with payer guidelines and submitted to appropriate parties.
Field Reimbursement Manager
Cencora/Tarsus
06.2023 - 05.2024
- Developed and implemented innovative reimbursement strategies resulting in improved access to healthcare products for patients
- Collaborated closely with cross-functional teams to provide expert guidance on reimbursement and coding practices, ensuring compliance with regulatory requirements
- Conducted comprehensive training sessions and educational programs for healthcare professionals, empowering them with knowledge on insurance coverage and reimbursement processes
- Led a high-performing team of reimbursement specialists, providing mentorship and support to effectively address reimbursement challenges for healthcare providers
- Educated healthcare professionals on patient support programs, including access and reimbursement support tools and services, to facilitate optimal patient care
- Provided specialized expertise on product-specific acquisition and access options, such as specialty pharmacy networks and specialty distribution channels
- Offered local insights on national/regional payer policies to educate providers on payer issues, coding changes, and appropriate claims submission processes
- Supported Cencora/Tarsus with product access initiatives, leveraging in-depth knowledge of commercial and government payer reimbursement and health reimbursement law
- Specialized in ophthalmology knowledge and support, ensuring comprehensive understanding and assistance in this specialized field
- Excelled in the development and maintenance of complex, client-driven reimbursement programs in highly competitive markets
- Demonstrated proficiency in claim denial management and facilitating patient access to bio-pharmaceuticals on the market
- Leads assigned Specialty Liaison team, managing and directing activities essential to providing the highest quality experience for patients in specialty clinic
- Ensures Specialty Liaison team accountability and the consistent use of best practices for execution of the following critical responsibilities: prior authorizations, patient financial assistance, medication refills, patient appointments, and patient outreach
- Provides consistent, timely and ongoing performance coaching, feedback, training, and development to liaisons
Patient Care Outreach Supervisor
Shields Health Solutions
01.2021 - 06.2023
- Supervised patient care outreach team to ensure smooth operations and high-quality service delivery
- Developed and implemented patient outreach programs resulting in increased patient engagement and satisfaction
- Monitored and evaluated patient care metrics to identify areas for improvement and implement necessary changes
- Trained and mentored staff members to effectively communicate and provide compassionate care to patients
- Managed communications between pharmacy and medical staff to ensure smooth operations and patient safety
- Collaborated with pharmaceutical companies to optimize medication supply and pricing for patients
- Developed training programs to educate healthcare providers on new pharmaceutical products and treatment protocols
Pharmacy Liaison
Shields Health Solutions
01.2020 - 01.2021
- Conducted medication reviews and provided medication counseling to patients to enhance adherence and health outcomes
- Offered effective medical advice to patients in following medication regimen, undergoing outbound therapy, and obtaining prescription refills in coordination with hospital clinicians
- Ensured smooth delivery of patient care in liaison with centralized Patient Service Center and Physicians in a professional manner
- Resolved insurance related issues, including prior authorizations (PAs), and assisted patients with various forms of financial assistance
Senior Account Clinical Representative
Northwell
01.2019 - 01.2020
- Successfully managed key accounts and built strong relationships with healthcare professionals, resulting in increased sales
- Developed and implemented effective strategies to meet sales targets and exceed revenue goals
- Provided comprehensive product training to healthcare professionals, ensuring optimal use and customer satisfaction
Customer Service Specialist and Patient Care Supervisor
BriovaRx Specialty Pharmacy
01.2013 - 01.2019
- Processed payments as per claims' authenticity in accordance with insurance carriers' criteria to eliminate all inconsistencies and redundancies
- Followed all federal and state regulations in researching complaints, appeals, and grievances from multiple sources, such as members, providers, and regulatory bodies
- Confirmed on-time delivery of payments for seamless medical services provision by promptly following up on denied and outstanding claims
Pharmacy Technician and Store Manager
CVS Pharmacy
01.2007 - 01.2013
- Extensive experience in dispensing medications and managing inventory in a fast-paced pharmacy environment
- Proficient in using pharmacy software systems to process prescriptions and track patient profiles
- Skilled in conducting medication reconciliation and counseling patients on proper usage and side effects
Education
Bachelor of Science - Healthcare Administration
Keiser University
Fort Lauderdale, FLBachelor of Science - Psychology
Keiser University
Fort Lauderdale, FLAssociate of Science - Childhood Education
Queens College
Flushing, NYSkills
- Utilization review
- Communication
- Problem Solving
- Relationship Building
- File management
- Documentation
- Revenue cycle management
- Patient account reviews
- HIPAA compliance
- Issue resolution
- Claims management
- Reimbursement management
- Analytics skills
- Written and verbal communication
- Insurance verification
Certification
- CPhT - Certified Pharmacy Technician
Languages
Spanish
Native or Bilingual
Timeline
Field Reimbursement Manager
Johnson & Johnson, Janssen Pharmaceuticals
05.2024 - Current
Field Reimbursement Manager
Cencora/Tarsus
06.2023 - 05.2024
Patient Care Outreach Supervisor
Shields Health Solutions
01.2021 - 06.2023
Pharmacy Liaison
Shields Health Solutions
01.2020 - 01.2021
Senior Account Clinical Representative
Northwell
01.2019 - 01.2020
Customer Service Specialist and Patient Care Supervisor
BriovaRx Specialty Pharmacy
01.2013 - 01.2019
Pharmacy Technician and Store Manager
CVS Pharmacy
01.2007 - 01.2013
Bachelor of Science - Healthcare Administration
Keiser University
Bachelor of Science - Psychology
Keiser University
Associate of Science - Childhood Education
Queens College
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