KELLEEN A. MASON

• Responsible for the daily workflow of rejected prior authorization and non-formulary claims within compliant guidelines
• Communicated directly with the Lead Prior Authorization Claims Specialist with all identified challenges, successes, and concerns from all internal and external providers.
• Worked with prior authorization/interchange adjudication on a daily basis.
• Communicate with other team members throughout RCO, operations, customer success and cost containment to deliver additional value to contracted LTC facilities
• Work special projects as needed
• Research and respond to customer billing issues/reports in timely manner

• Effectively managed the work volume by handling inbound calls faxed Prior Authorization requests both at the same time, while utilizing appropriate courteous and professional behavior.

• Sort incoming faxes in compliance with departmental and client requirements.

• Manage case load of all clients by researching and triaging incoming fax requests. Use eligibility systems such as

Frameworks, DocuTracks, and SharePoint to identify the type of request and create, route, and/or complete appeals or

requests in accordance with department processes.

• Process External Review appeal and Prescriber Peer to Peer requests according to federal, client, and state mandated

guidelines

• REMOTE
• Entered and processed 120+ new and refill faxed, ERX, verbal, and transferred prescriptions per 8-to-10-hour shift
• Fax, email, and call doctor's offices and patients to obtain and maintain prescription, patient, medical supply, delivery shipping, and billing information
• Once completed IM all necessary parties involved
• Resolved non-routine issues like third party billing, computer system and customer service issues
• Reviewed and verified customer information and insurance provider information
• Performed wide range of pharmacy operations with strong commitment to accuracy, efficiency, and service quality

• Responsible for Human Resource procedures such as hiring, scheduling, payroll, benefits management, and all other administrative duties at Pharmacy level.

• Conduct team meetings on a regular basis to promote open communications between Pharmacist, order entry, pharmacy service technician and billing departments, to enhance cooperative efforts.

• Implemented procedures necessary for compounding, mixing, packaging, and labeling.

• Collaborated with Pharmacy Operations Manager and Pharmacist in Charge to maintain daily operations.

• Resolved issues with customers and pharmacy personnel by utilizing active listening, effective communication, and mediation skills.

• Developed policies and procedures that would streamline pharmacy management and make it more efficient.

• Processed over 400 prescriptions per 8 - 12hr day in a busy LTC pharmacy achieving decreased customer wait times.

• Train new and existing employees on the day-to-day processes of the pharmacy and order entry.

• Led team of 12 in interpreting, validating, and filling prescription orders.

• Run and print out Facilities prescription labels/ orders between each run via the Framework program, specialty order prescriptions, Canister and Auto Medication fill for Long Term Care Facilities Daily and nightly Tote delivery.

• Stocked, labeled, and inventoried medication to keep accurate records.

• Communicated with prescribers to verify medication dosages, refill authorizations and patient information.

• Enter and process new and refill prescriptions 50+ per day depending on workload
• Adjudicate test claims, process the weekly refill report queue/order assignment queue, process patient delivery tickets
• Fax, email, and call doctor's offices and patients to obtain and maintain prescription, patient, billing information, and lab reports, scan in, upload, and input lab results into the patient's profile
• Consulted with insurance company representatives to complete claims processing, resolve concerns and reconcile payments.

• Census analysis for end of the month billing reports Crediting returns Data entry/10 key, phone ordering Inventory maintenance and ordering stock 30-50 calls per 8 hr.

• Set up patient profiles, kept all medical history up to date, processed and adjudicated new and refill prescriptions for all LTC facilities.

• Remote work from home via the Citrix and Framework programs.

• Prepared invoices on bi-weekly to monthly basis, effectively sending out bills for upwards of 25-40 LTC Facilities

monthly. Compiled various reports related to Cycle Filling and 30-day blister card fills.

• Evaluated aging reports to identify members to be included in monthly outbound collection calls.

• Interacted with Order Entry, Dispensing Pharmacy and Delivery departments, effectively building lasting relationships. • Managed all accounts payable functions for a busy 8-person Department.

• Resolved claim rejection issues over phone with 75-100 customers every 8-12hr shift.

• Assessed caller accounts to determine Prescription benefits, identify service needs and resolve issues.

• Provided per prescriptions benefit plans to Providers, Pharmacies and clients with formularies and updates to plan.

• Cross-trained and provided back up for Customer Service Managers and Prior Authorization Team.

• Facilitated inter-departmental communication to effectively provide customer support.