Summary
Overview
Work History
Education
Skills
Certification
Languages
Timeline
Generic

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, FL

Bachelor of Science - Psychology

Keiser University
Fort Lauderdale, FL

Associate of Science - Childhood Education

Queens College
Flushing, NY

Skills

  • 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
GINA DURAN