Lillian Brown
Lehigh Acres
Summary
Detail-oriented Clinical Appeal Specialist with a strong focus on healthcare regulations and clinical data analysis, ensuring accurate coding and medical necessity assessments.
Overview
18
18
years of professional experience
Work History
Clinical Appeal Specialist & Clinical Advisor
Genesis Care USA of Florida
Fort Myers
05.2008 - Current
- Interacted professionally with other departments within the organization regarding patient care issues.
- Monitored workloads daily utilizing various tracking systems and databases.
- Generated letters informing providers of decisions made during the review process.
- Maintained current knowledge of state and federal regulations governing healthcare reimbursement practices.
- Provided technical assistance to staff members regarding medical terminology and coding processes.
- Conducted retrospective reviews on a variety of cases involving utilization management or case management activities.
- Attended meetings, seminars, webinars related to changes in healthcare policy or procedure.
- Facilitated conference calls between physicians and other clinicians as needed.
- Assessed the appropriateness of care, services rendered, and coding accuracy according to established criteria.
- Processed requests for prior authorization in accordance with company policies and procedures.
- Engaged in proactive problem solving techniques when necessary to resolve complex situations.
- Participated in peer-to-peer discussions concerning difficult or sensitive cases.
- Analyzed clinical data including laboratory results, diagnostic studies, and medication profiles as part of the review process.
- Reviewed clinical information to determine medical necessity of services requested by providers and facilities.
- Maintained positive working relationship with fellow staff and management.
- Pulled patient records and transferred information to appropriate parties.
- Answered questions and fulfilled requests with friendly and knowledgeable service.
Education
EMT Basic Certificate - EMS
NY EMS
Cornwall-on-Hudson, NY01-2006
High School Diploma -
Riverdale High School
Fort Myers, FL06-1997
Skills
- Medical billing
- Clinical review
- Prior authorization
- Coding accuracy
- Healthcare policy
- Peer to Peers with insurance companies
Timeline
Clinical Appeal Specialist & Clinical Advisor
Genesis Care USA of Florida
05.2008 - Current
EMT Basic Certificate - EMS
NY EMS
High School Diploma -
Riverdale High School