MARIE MANDING
Hanover Park,IL
Summary
To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
25
25
years of professional experience
Work History
Benefit Verification Specialist
CVS Caremark Specialty Pharmacy
08.2020 - Current
- Demonstrated strong commitment to customer satisfaction, going above and beyond to ensure the highest level of care for each patient served.
- Contributed to departmental goals by consistently meeting or exceeding performance metrics related to benefit verification accuracy and turnaround time.
- Increased accuracy in data entry through meticulous attention to detail when inputting patient demographics and insurance information into the system.
- Verified eligibility and compliance with authorization requirements for service providers.
- Established strong relationships with key contacts at insurance companies, streamlining communication channels when resolving issues pertaining to approvals or denials.
- Streamlined pharmacy workflow for improved efficiency by coordinating with healthcare providers on prescription authorizations.
- Managed a high volume of incoming calls, maintaining professionalism while effectively addressing the needs of callers seeking assistance with prior authorizations.
- Ensured compliance with HIPAA regulations during all aspects of benefit verification process, protecting patient privacy.
- Proven ability to learn quickly and adapt to new situations.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
- Worked well in team setting, providing support and guidance.
Patient Referral Coordinator/Prior Authorization Specialist
Northwestern Medicine
10.2018 - 08.2020
- Assisted with day-to-day operations, working efficiently and productively with all team members.
- Communicated with insurance companies to verify coverage and obtain authorizations for medical treatments and procedures.
- Acted as the main point of contact for patients, doctors, and hospital staff by closely reviewing medical charts and maintaining high levels of communication.
- Facilitates pre-authorization for Infusion Therapy/Rehab
Therapy between ordering physicians and insurance carriers,
through online tools and/or direct phone call. - Review and analyze scripts/medications/progress notes entered in patient's charts before their scheduled appointment.
- Performs precertification by gathering all required documents are complete before submitting to insurance carrier per payor requirements.
- Reduced turnaround time for prior authorization requests by utilizing electronic submission methods.
- Ensure all infusion medications, pain injections, and therapy
services are financially cleared before their scheduled
appointment. - Proactively analyzes account activity, identifies problems, and
initiates appropriate actions/resolutions - Monitors registration and scheduling, including insurance
eligibility and coverage through online tools or direct phone calls as necessary to ensure processing within prescribed quality standards. - Contributed to a high level of customer service by quickly addressing questions or concerns from patients regarding their coverage or denials.
- Self-motivated, with a strong sense of personal responsibility.
Medical Assistant/Patient Service Representative
NorthShore University HealthSystem
02.2010 - 10.2018
- Answer incoming calls from patients to schedule office visits,
follow-ups, procedures, infusion treatments, and/or urgency
requests due to patient symptoms/chief complaints. - Obtained and documented patient medical history, vital signs, and current complaints at intake.
- Supported duties for diagnostic and technical treatment procedures, such as setting up and operating special medical equipment and apparatus.
- Confirm appointments before their scheduled visit
- Coordinates and schedules procedures such as EGD and/or
Colonoscopy to each NorthShore facility. - Schedules General Anesthesia/MAC Sedation as ordered by
physician. - Process refill requests, update preferred pharmacy, enter lab/test orders on EPIC, relay test results based on physicians' findings.
- Initiate Prior Authorization for any prescribed medication such
as PPIs, Injectable and/or Infusion therapy drugs that are
mandated by their insurance policy. - Assisted physicians in providing high-quality care, completing insurance forms and handling referrals promptly.
- Participated in ongoing training programs related to HIPAA compliance, maintaining up-to-date knowledge on regulatory requirements.
- Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
Claims Auditor
Guarantee Trust Life Insurance
07.1999 - 07.2010
- Assures overall quality of all internal and external claims by auditing payments over the authorization limit of the Adjusters and Third Party Administrators.
- Provides Claim Management in areas that need further training, clarification, or change to avoid errors or misinterpretation.
- Monitors claim registers to determine that claim procedures and guidelines are followed and are processed promptly.
- Audits work selected at random for each Adjuster/Third Party Associate to ensure quality standards are met for payments/denials as defined by the policy provisions, Coordination of Benefits, and State Mandates
- Adjudicate accident and sickness medical claims for liability as defined by the policies, including review of medical records and claim investigation
- Responds and confers to State Compliance Dept inquiries within the allotted time frame regarding state statutes and laws as well as with Special Risk Underwriter to clarify policy provisions, languages, and definitions.
- Followed up on potentially fraudulent claims initiated by claims representatives.
- Conducted thorough investigations of medical claims to ensure proper payment or denial.
- Collaborated with other departments as needed to ensure seamless communication during claims process, promoting effective teamwork across the organization.
- Maintained compliance with industry regulations by staying current on policy changes and updating procedures accordingly.
- Collaborated with healthcare providers to obtain the necessary documentation for claim support.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures, and HIPAA regulations.
- Participated in cross-functional teams to address systemic issues within the organization, contributing insights from a medical claims perspective.
- Demonstrated respect, friendliness, and willingness to help wherever needed.
Education
Associate of Applied Science - Health Information Technology
William Rainey Harper College
Palatine, IL05.2015
Skills
- HIPAA Compliance
- Microsoft Office Application
- Insurance Verification
- Medical Terminology
- Medical claims coding
- ICD-10 Coding/ICD-9 Coding
- Epic Systems
- Authorizations understanding
- Medicare and Medicaid knowledge
- Electronic Health Records Proficiency
Timeline
Benefit Verification Specialist
CVS Caremark Specialty Pharmacy
08.2020 - Current
Patient Referral Coordinator/Prior Authorization Specialist
Northwestern Medicine
10.2018 - 08.2020
Medical Assistant/Patient Service Representative
NorthShore University HealthSystem
02.2010 - 10.2018
Claims Auditor
Guarantee Trust Life Insurance
07.1999 - 07.2010
Associate of Applied Science - Health Information Technology
William Rainey Harper College
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