Joshua C. Saturne
Miramar,FL
Summary
Dynamic Grievance and Appeals Coordinator at Sunshine Health with a strong background in policy interpretation and appeals processes. Adept at utilizing analytical thinking to resolve denied claims, ensuring compliance with HIPAA regulations. Committed to continuous learning and advocating for patient needs, driving efficient outcomes in healthcare settings.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Grievance and Appeals Coordinator
Sunshine Health
Sunrise, FL
05.2021 - Current
- Maintained records of all appeal activities in a timely manner.
- Responded promptly to all correspondence from third-party payers regarding patient claims.
- Identified reasons behind denied claims and worked closely with insurance carriers to promote resolutions.
- Assisted with the development of new policies and procedures related to appeals processes.
- Advised patients on the status of their appeals and any follow-up actions required.
- Reviewed denied claims for potential resubmission or reconsideration.
- Tracked progress of ongoing appeals cases using computer software systems, including Trucare, Microsoft Excel and Microsoft Word.
- Maintained updated knowledge through continuing education and advanced training.
Prior Authorization Nurse
Sunshine Health
Sunrise, FL
02.2019 - 05.2021
- Employed Microsoft Excel and Word to streamline tasks efficiently.
- Gather missing information from providers and their staff as needed.
- Proficient in operating Trucare software.
- Executed reviews using InterQual standards in combination with organizational guidelines.
- Provided guidance and support to staff members on prior authorization processes.
- Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
- Collaborated with internal staff members to resolve discrepancies or issues related to prior authorizations.
- Educated healthcare providers on prior authorization requirements and insurance formulary changes.
- Participated in multidisciplinary team meetings to discuss complex cases requiring prior authorization.
- Responded promptly to inquiries from providers, patients and payers regarding status of prior authorization requests.
- Input claim, prior authorization, and other important medical data into system.
- Communicated authorization decisions, including approvals and denials, to healthcare providers and patients.
Pediatric Intensive Care Unit
Nicklaus Children’s Hospital
07.2016 - 02.2019
- Admit patients to the unit and quickly work to stabilize them and situate accompanying family members.
- Advocate for patients and their guardians.
- Assess patients for changes in condition and report to physicians in a timely manner.
- Work alongside various members of the medical team, including fellow nurses, respiratory therapists and care assistants..
- Educate patients and parents on their condition and treatment plans and interventions.
- Develop and implement care plans for my patients.
Education
Bachelor of Science - Nursing
University of Miami
Miami, FL05.2016
Skills
- Policy interpretation
- Data entry proficiency
- Continuous learning mindset
- Analytical thinking
- Appeals process proficiency
- HIPAA compliance
- Multitasking skills
Licensures And Certifications
- Registered Nurse (RN), 07/2016, Current
Certification
- Pediatric Fundamental Critical Care Support (PFCCS) certificate received August 2018
Timeline
Grievance and Appeals Coordinator
Sunshine Health
05.2021 - Current
Prior Authorization Nurse
Sunshine Health
02.2019 - 05.2021
Pediatric Intensive Care Unit
Nicklaus Children’s Hospital
07.2016 - 02.2019
Bachelor of Science - Nursing
University of Miami
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