Kerry Surgeon
Kernersville,NC
Summary
Results-driven case management professional with over 20 years of experience in benefits investigation, prior authorizations, medical & pharmacy claims resolution, serving as SME for staff & providers and client advocacy. Expertise in both medical and pharmacy benefit coverage, appeals, and denial management. Extensive knowledge of ICD-10 codes and compliance with payer criteria. Proven track record in collaborating with providers, clients, and internal teams to streamline the reimbursement process. PACS-certified for maximum knowledge of best reimbursement processes. Collaborates seamlessly with multidisciplinary teams and adapts to dynamic situations to ensure optimal client outcomes. Experienced with Salesforce, EMR, Athena, EPIC and Artemis platforms.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Case Manager
UBC, Argenx Program
02.2024 - Current
- Handle reimbursement for Vyvgart and Vyvgart Hytrulo.
- Perform benefit investigations, determine prior auth needs, and track appeals.
- Point of contact/SME for patients, specialty pharmacies and providers.
- Monitor reverification and reauthorization processes.
- Support PAP eligibility and enrollment.
- Monitored ongoing cases closely, adjusting case management strategies as needed based on evolving circumstances or new information.
- Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
- Enhanced communication between clients and providers through consistent follow-ups and progress updates.
- Advocated for client rights when interacting with external agencies or institutions, ensuring fair treatment at all times.
- Achieved positive client outcomes by developing and implementing comprehensive case management plans.
- Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
- Contributed to team discussions and case conferences actively, sharing insights and expertise with colleagues to optimize client support strategies.
- Developed and implemented comprehensive case management plans to address client needs and goals.
- Improved client satisfaction by efficiently addressing concerns or grievances in a timely manner while adhering to individual tailored needs.
- Increased client satisfaction through diligent follow-up and personalized support.
- Collaborated with multidisciplinary teams to address client needs and formulate tailored support strategies.
- Participated in regular professional development opportunities to stay current on best practices within the field of case management.
- Enhanced team collaboration by leading regular case review meetings, promoting unified approach to client care.
- Established and maintained relationships with key stakeholders.
Sr. Reimbursement Specialist, Lead
UBC, Janssen Spravato Program
12.2023 - 02.2024
- Reviewed VOB/SOB cases to ensure completeness and accuracy.
- Mentored other reimbursement specialists and supported case cleanup.
- Tracked prior authorizations and appeals with a focus on outcome improvement.
- Facilitated communication between clients and payers to resolve disputes over coverage determinations and negotiate favorable payment terms.
- Conducted regular audits of client accounts to identify discrepancies or potential issues requiring further investigation or resolution.
- Collaborated with cross-functional teams to develop strategies that improved claims processing accuracy and speed.
- Implemented process improvements that led to faster turnaround times for appeals submission, increasing successful outcomes for clients.
- Trained new team members on internal systems and procedures, fostering a collaborative work environment focused on continuous improvement.
- Managed high-volume claim submissions efficiently, reducing errors and ensuring timely reimbursements for clients.
- Provided exceptional customer service to clients by addressing inquiries promptly, accurately, and professionally.
- Maintained up-to-date knowledge of coding changes, payer policies, and regulatory requirements to ensure compliance in all reimbursement activities.
- Coordinated with insurance providers to verify customer's policy benefits in relation to claims.
- Delivered timely information to insurance representatives to resolve common and complex issues.
- Employed clinical and billing codes expertise to correct billing inconsistencies.
- Prevented delays and claim denials by correcting information prior to submission.
- Guided office staff on how to effectively complete prior authorization forms and appeals documentation to achieve positive results.
- Trained department employees in proper billing and accounting procedures.
- Verified client information by analyzing existing evidence on file.
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Communicated effectively with staff members of operations, finance and clinical departments.
- Reviewed outstanding requests and redirected workloads to complete projects on time.
- Participated in industry conferences and workshops, staying informed on the latest trends and developments in reimbursement processes.
- Built proactive, client-specific edits into system to prevent future denials.
Sr. Reimbursement Specialist / Case Manager
UBC, Janssen Spravato Program
12.2022 - 02.2024
- Performed benefit investigations and initiated prior authorizations.
- Used CoverMyMeds and insurance portals to track statuses.
- Collaborated with providers and client reps on case progression.
- Reported REMS events and facilitated program education
- Identified opportunities for revenue growth by analyzing payer contracts and recommending adjustments to fee schedules and billing practices.
- Optimized billing workflows by analyzing trends in payer denials and implementing corrective actions accordingly.
- Conducted comprehensive reviews of medical documentation to ensure appropriate levels of support were provided for each claim submitted.
- Served as a subject matter expert within the organization on complex reimbursement scenarios, consistently delivering accurate solutions.
- Built proactive, client-specific edits into system to prevent future denials.
- Compiled department-specific reports to help senior managers identify trends and improve progress.
- Checked documentation for accuracy and validity on updated systems.
- Prepared insurance claim forms or related documents and reviewed for completeness.
- Maintained confidentiality of patient finances, records, and health statuses.
- Coordinated with contracting department to resolve payer issues.
- Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
- Provided crisis intervention support for clients experiencing emergencies, using appropriate techniques to de-escalate situations safely.
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Fostered open lines of communication with clients'' families and support networks, involving them in the case management process as appropriate.
- Managed crisis situations with empathy and professionalism, ensuring client safety and continuity of care.
- Implemented feedback system for clients to share their experiences, enhancing service quality through direct input.
- Developed resource directory for clients, simplifying their search for essential services.
Authorization Specialist / Benefits Coordinator
EmergeOrtho
09.2008 - 12.2022
- Benefits verification including determining potential out-of-pocket cost for patient based on current coverage and provider charges
- Submitted prior auth requests and tracked denial/appeal outcomes.
- Coordinated peer reviews for insurance-mandated criteria.
- Maintained prior authorization tools and reporting sheets.
- Increased accuracy by diligently reviewing and verifying patient eligibility, coverage, and benefits information.
- Ensured prompt resolution of denied claims through comprehensive analysis of denial reasons and timely submission of necessary documentation for reconsideration or appeal.
- Demonstrated adaptability with changing insurance requirements, maintaining up-to-date knowledge through continuous education efforts.
- Developed strong relationships with insurance representatives to expedite approvals and resolve issues promptly.
- Enhanced departmental efficiency with thorough knowledge of insurance guidelines and medical terminology.
- Expedited claim processing by submitting complete and accurate information in accordance with payer requirements.
- Promoted positive customer experiences by addressing concerns or questions related to authorizations in a professional manner.
- Resolved discrepancies with client applications to verify eligibility.
LTC Pharmacy Technician
Pharmerica
08.2001 - 09.2008
- Handled medical and pharmacy billing & claim denials for LTC facilities.
- Traveled for chart reviews, drug exchanges, and inventory assessments.
- Solved customer problems in-person or over telephone by providing assistance with placing orders, navigating systems, and locating items.
- Performed various pharmacy operational activities with strong commitment to accuracy, efficiency, and service quality.
- Proactively identified potential issues or discrepancies in medication orders, collaborating closely with pharmacists to resolve them quickly.
- Resolved third-party billing, computer system and customer service issues.
- Provided exceptional customer service, fostering positive relationships with both new and existing clients/providers.
- Expedited insurance claim resolutions by liaising with healthcare providers and insurance companies on patient behalf.
Education
Pre-Nursing -
Guilford Technical Community College
Jamestown, NCGeneral Education -
Guilford Technical Community College
Jamestown, NCSkills
- Pharmacy & Medical Benefits Verification/Prior Authorizations Including Claims Resolution & Denial Management
- Appeals Processing & Peer Review Coordination
- Patient Support & PAP Assistance
- REMS Program Compliance
- ICD-10 Coding & Documentation
- HCP & Patient Communication
- Client advocacy and support
- Case management
- Relationship building
- Conflict resolution
- Staff education and training
- Client relationship management
- Goal setting
- Time management
- Documentation and reporting
- Positive attitude
- Excellent Communication Skills
Certification
Prior Authorization Certified Specialist (PACS) – 2024-11
Timeline
Case Manager
UBC, Argenx Program
02.2024 - Current
Sr. Reimbursement Specialist, Lead
UBC, Janssen Spravato Program
12.2023 - 02.2024
Sr. Reimbursement Specialist / Case Manager
UBC, Janssen Spravato Program
12.2022 - 02.2024
Authorization Specialist / Benefits Coordinator
EmergeOrtho
09.2008 - 12.2022
LTC Pharmacy Technician
Pharmerica
08.2001 - 09.2008
Pre-Nursing -
Guilford Technical Community College
General Education -
Guilford Technical Community College
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