Jennifer Abbey
Land O Lakes,FL
Summary
Seasoned Specialist offering fifteen (15) years of comprehensive experience interpreting and implementing quality assurance standards and investigating customer complaints and non-conformance issues. Practiced and knowledgeable professional possessing excellent problem solving and analytical skills paired with strong knowledge of QA terms, tools and methodologies. Committed to improving overall business processes.
Overview
6
6
years of professional experience
Work History
Performance Monitoring Specialist
Centene
Land O Lakes, FL
11.2022 - Current
- Participates in the development and ongoing compliance review to ensure that elements accurately capture adherence with required performance standards
- Reviews program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of review tool elements, departmental process, staff training, and departmental standards
- Participates in meetings to discuss review findings, areas of opportunity and recommendations for improvement
- Conducts risk assessments and trends with teams to ensure accuracy on audits
- Follow departmental guidelines and processes at a senior level.
- Ensured timely completion of all assigned tasks within set deadlines.
- Participated in ongoing training and compliance activities.
- Conducted risk assessments to identify potential areas of fraud or non-compliance.
- Performed regular reviews of the company's operations for compliance with laws and regulations.
- Provided guidance on improving internal controls over business processes.
- Participated in special projects related to due diligence investigations as required.
Durable Medical Equipment Coordinator
Wellcare Corporation (now centene)
Land O Lakes, FL
07.2019 - 11.2022
- Subject matter expert for DME to include research prior authorizations, claims, and benefits to determine overall eligibility
- Maintain compliance guidelines set forth by CMS and Department to meet quality standards
- Review clinical documentation and apply Medicare/Medicaid guidelines to determine medical necessity
- Responsible for following up with Physicians, and Vendors to request additional information to meet timelines and guarantee determination
- Maintain accuracy of approvals, document a detailed summary of determination criteria, and communicate decisions to Providers when necessary
- Additionally, assist management in escalation requests.
- Maintained accurate records of all authorizations, denials, appeals and other related paperwork.
- Reviewed and processed prior authorization requests from healthcare providers to determine eligibility for services.
- Facilitated communication with providers regarding authorization status, payer requirements and coverage criteria.
- Provided assistance to patients by answering questions about their coverage plans or benefits available through their insurance carriers.
- Conducted training sessions for new employees on the process of obtaining pre-authorization from health insurance carriers.
Executive Secretary
The Wrist and Hand Center
Tampa, FL
01.2018 - 07.2019
- Leader role in maintaining an organized office while completing direct projects from the Physician using all major Microsoft programs
- Responsible for office dictations to finalize office notes and utilizing proper coding measures for billing purposes
- Lead role in front desk operations including check in/out, insurance verifications, copay calculations, coinsurance calculations for surgical procedures, phone system and filing
- Compliance role includes direct work with the office Attorney on projects for CMS, billing, coding specifications for that year
- Gained knowledge in audits, appeals, grievances, and HIPAA compliance.
- Greeted and directed visitors, answered phone calls, and provided general administrative support.
- Maintained filing system for all documents related to executive activities.
- Managed calendar of appointments for executives; scheduled appointments with internal and external contacts.
- Monitored emails received by executive personnel; responded promptly when appropriate.
- Provided assistance in resolving customer complaints or inquiries in a timely manner.
- Ensured that all records were maintained in accordance with company policies and procedures.
- Performed research on specific topics as requested by management personnel.
- Reviewed incoming correspondence; distributed materials accordingly.
- Assisted with special projects as needed; provided input on project plans when requested.
- Created and maintained computer- and paper-based filing and organization systems for records, reports and documents.
- Facilitated communications by forwarding emails, transferring calls and filing documents.
- Filtered important calls and spam calls to help executives prioritize specific clients and expedite daily operations.
- Coordinated multiple schedules using online calendaring system.
Education
Juris Master - Compliance & Regulation
Florida State University
Tallahassee05-2024
Bachelor of Sciences - Healthcare Administration
University of Phoenix
10.2022
Skills
- Collaborative
- Detailed Thinker
- Compliance/Audit Experience
- Risk mitigation strategies
- Analytical
- Senior Level/Leadership
- Problem Solving
- Adaptable
- Communication
- Quality Assurance
- Root Cause Analysis
- Customer Relations
- Expert in Microsoft, and Windows
- Issue Resolution
- Internal Auditing
- Ethical standards
- Compliance standards
- Regulatory Compliance
Key Experience
- Fifteen (15) years in the healthcare field in various roles from front desk, insurance authorizations, patient care, compliance, and auditing
- Extensive compliance and regulatory experience in healthcare
- Claims, Coding, Appeals, and healthcare revenue experience
- Two years of leadership experience
Leadership Experience
- National Society for Leadership & Success (NSLS) recognition
- Advisory Board at Florida State University Juris Master Program
Affiliations
Involved in our local church ministry with the youth, music, and any other volunteer opportunities that are available.
References
References available upon request.
Timeline
Performance Monitoring Specialist
Centene
11.2022 - Current
Durable Medical Equipment Coordinator
Wellcare Corporation (now centene)
07.2019 - 11.2022
Executive Secretary
The Wrist and Hand Center
01.2018 - 07.2019
Juris Master - Compliance & Regulation
Florida State University
Bachelor of Sciences - Healthcare Administration
University of Phoenix