Matthiaus Jeampierre Leon Moran
Pharmacutical Case & Reimbursement Specialist
Houston,Texas
Summary
Quality-driven Reimbursement Manager with exemplary skills in supervising talented team and providing required training. Meticulous professional accurately reviewing patient accounts and assisting with issue resolution. Delivering exemplary talents in Pharmaceutical Reimbursement to drive corporate success.
Overview
11
11
years of professional experience
4
4
Certifications
3
3
Languages
Work History
Senior Claims Reimbursement Specialist
United Biosource Corporation
02.2023 - Current
- Professional representation of manufacturer's patient and physician access services
- Provide information on relevant access topics related to our client's products
- Reviewing patient-specific information in cases where the site has
- Current, unrestricted driver's license in state of residence
- Demonstrated proficiency with Microsoft Word, PowerPoint and Excel; current driver's license and safe driving record; use of computer, mobile phone, printer and fax
- Accurately enter and maintain data as required in client database and patient files and utilize the client database to monitor outstanding items on each client case file
- Ensure files are complete so team can determine the current status
- Participate in conference calls with Client Sales Representatives, client management and physicians' offices regarding status of cases, drug orders and status of alternative funding
- Provide day-to-day oversight and coordination of caseload to ensure all case elements and tasks are completed timely and ensure cases move through the process as required
- Act as single point of contact responsible for prior authorization and appeal processing communications to patients, healthcare providers, field reimbursement representatives and other external stakeholders
- Communicate patient benefits and responsibility timely and accurately
- Assess and refer patients appropriately for special programs/services when appropriate
- Performs quality checks on cases and report trends to leadership
- Responsible for good housekeeping techniques, adhering to quality and production standards while complying with all applicable company, state and federal safety and environmental programs and procedures
- Troubleshoot complex cases, spanning multiple disease-states, while interfacing with key stakeholders (internal/external) to ensure optimal start to therapy
- Report Adverse Drug Events that have been experienced by the patient in accordance pharmaceutical requirements
- Recognize a product quality complaint and forward caller/written information to a manufacturer
- Product launch
- Rare disease bio similar
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations, and procedural costs.
- Partnered with physicians, social workers, activity therapists, nutritionists, and case managers to develop and implement individualized care plans and documented patient interactions and interventions in electronic charting systems.
- Liaised with social worker to expedite financial assistance not covered by insurance.
- Collaborated with an interdisciplinary team to determine timely delivery of services.
- Utilized trauma-informed approach to promote healing and empowerment for clients.
- Provided education on health and nutrition for patients to maintain healthy habits and wellbeing.
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Created and managed budgets, efficiently allocating resources for social and community service projects.
- Researched best practices and developed strategies to improve program outcomes.
- Provided leadership, guidance and support to staff members.
- Monitored program performance and outcomes for successful delivery of services.
- Observed strict data confidentiality procedures to protect patients' information.
- Reviewed billing and collections process and determined improvements to streamline workflows.
- Held weekly staff meetings and implemented team building exercises, which promoted positive working environment.
- Monitored accounts receivables by reviewing payor account listings.
- Maintained strong knowledge of medical terminology and procedures.
- Guided office staff on how to effectively complete prior authorization forms and appeals documentation to achieve positive results.
- Employed clinical and billing codes expertise to correct billing inconsistencies.
- Trained department employees in proper billing and accounting procedures.
- Contributed knowledge to help improve financial management, billing and tracking systems.
- Helped minimize escalations by reaching out to clients in advance of expected problems.
- Delivered timely information to insurance representatives to resolve common and complex issues.
- Followed up on denied and unpaid claims to resolve problems and obtain payments.
- Built proactive, client-specific edits into system to prevent future denials.
- Monitored and documented accounts receivable trends and account-specific profitability.
- Created documents in accordance with payer guidelines and submitted to appropriate parties.
Case Manager Supervisor
United Biosource Corporation
06.2021 - Current
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations, and procedural costs.
- Partnered with physicians, social workers, activity therapists, nutritionists, and case managers to develop and implement individualized care plans and documented patient interactions and interventions in electronic charting systems.
- Liaised with social worker to expedite financial assistance not covered by insurance.
- Collaborated with an interdisciplinary team to determine timely delivery of services.
- Provided education on health and nutrition for patients to maintain healthy habits and wellbeing.
- Coordinated services with other agencies, community-based organizations, and healthcare professionals to provide useful benefits to clients.
- Developed and implemented training programs for staff.
- Coordinated individual referrals to obtain community services, advocate for client needs and resolve roadblocks.
- Observed strict data confidentiality procedures to protect patients' information.
- Reviewed billing and collections process and determined improvements to streamline workflows.
- Held weekly staff meetings and implemented team building exercises, which promoted positive working environment.
- Monitored accounts receivables by reviewing payor account listings.
- Maintained strong knowledge of medical terminology and procedures.
- Guided office staff on how to effectively complete prior authorization forms and appeals documentation to achieve positive results.
- Prevented delays and claim denials by correcting information prior to submission.
- Compiled department-specific reports to help senior managers identify trends and improve progress.
- Contributed knowledge to help improve financial management, billing and tracking systems.
- Trained department employees in proper billing and accounting procedures.
- Employed clinical and billing codes expertise to correct billing inconsistencies.
- Coordinated with insurance providers to verify customer's policy benefits in relation to claims.
- Helped minimize escalations by reaching out to clients in advance of expected problems.
- Delivered timely information to insurance representatives to resolve common and complex issues.
- Created documents in accordance with payer guidelines and submitted to appropriate parties.
- Monitored and documented accounts receivable trends and account-specific profitability.
- Built proactive, client-specific edits into system to prevent future denials.
- Followed up on denied and unpaid claims to resolve problems and obtain payments.
Program Manager
United Biosource Corporation
01.2021 - Current
- Responsible for implementing and maintaining the effectiveness of the program
- Interacted with customers and clients to identify business needs and requirements.
- Coached team members on productivity strategies to accomplish challenging goals.
- Addressed and resolved technical, financial, and operational concerns by working with team members and directors.
- Met with project stakeholders on regular basis to assess progress and make adjustments.
- Worked with subject matter experts to develop and implement mentoring programs to promote better learner experiences.
- Demonstrated strong writing and presentation skills to develop briefs, memorandums and analytical reports for clients.
- Designed and developed programs and projects for dissemination to personnel.
- Engaged and worked alongside cross-functional stakeholders to manage strategic initiatives.
- Leveraged project management processes and tools to define and execute projects.
- Managed and supervised administrative and daily program operations, complying with policies and regulations.
- Facilitated workshops and conducted one-on-one training to educate team members.
- Identified program obstacles and communicated possible impacts to team.
- Devised creative solutions to critical customer and user needs.
- Managed multiple strategic projects with numerous sub-projects or workstreams.
- Participated in pilot tests and revised programs based on feedback and results.
- Developed and maintained logistics workflows, procedures and reports.
- Participated in vendor selection and management process for program initiatives.
- Collaborated with business leadership to set priorities based on business needs, resource capacity and risk exposure.
- Built teams to address project goals and objectives for multiple projects.
- Provided program management expertise in lean Six Sigma strategies and agile methods, practices and execution.
- Established milestones and objectives based on input from functional areas and stakeholders.
- Manage team of call center associates to promote a working team environment and ensure best practices are shared
- Works to develop employee's skills, evaluates performance and provides feedback
- Oversees resolution of employee relations issues and performance standards, productivity, and service standards
- Conducts hiring, training, and evaluation of staff
- Provide on-going coaching to each Customer Service Associate (CSA) on their team concerning quality, reliability, accountability, and productivity
- Ensure service levels and performance guarantees are met
- Work with Call Center Manager to implement strategic business work plan goals
- Tracks and periodically reports progress to management
- Assist in development of Call Center programs and process improvements to enhance the level of internal and external customer service provided
- Serve as a point of escalation for calls requiring a higher degree of expertise or discretion to resolve customer issues and ensure timely resolution
- Backup platform team
- May take overflow calls
- Special projects as assigned.
Field Reimbursement Manager
CPSI
07.2021 - 09.2022
- Account Maintenance: After initial education of the account, regular follow-up with the account is conducted either virtually, phone or in person to ensure proper coding and claims submission of products, identify any reimbursement issues and work with the account to resolve until appropriate payment is received
- Observed strict data confidentiality procedures to protect patients' information.
- Reviewed billing and collections process and determined improvements to streamline workflows.
- Maintained strong knowledge of medical terminology and procedures.
- Monitored accounts receivables by reviewing payor account listings.
- Guided office staff on how to effectively complete prior authorization forms and appeals documentation to achieve positive results.
- Prevented delays and claim denials by correcting information prior to submission.
- Compiled department-specific reports to help senior managers identify trends and improve progress.
- Contributed knowledge to help improve financial management, billing and tracking systems.
- Trained department employees in proper billing and accounting procedures.
- Coordinated with insurance providers to verify customer's policy benefits in relation to claims.
- Helped minimize escalations by reaching out to clients in advance of expected problems.
- Delivered timely information to insurance representatives to resolve common and complex issues.
- Created documents in accordance with payer guidelines and submitted to appropriate parties.
- Monitored and documented accounts receivable trends and account-specific profitability.
- Interacts with local and regional payers, including Medicare and Medicaid, as necessary to provide information about the procedure to support positive coverage and reimbursement
- Conducts reimbursement reviews with customers by examining paid EOB's, billing reports, or information provided by the practice to confirm the practice is billing correct codes
- Works as a liaison with the account, sales, and Access Program team to provide information required to complete timely benefit verifications
- Follows HIPAA policies and procedures to ensure protected health information is secure and not accessible to employees not authorized to view the information
- Adheres to the organization's appeal strategy and manages the on-going tactical application of the appeal strategy to ensure a successful reversal rate in conjunction with the Procedure Access Program team
- Reports reimbursement trends and global concerns to management to ensure corrective actions and mitigation of future occurrences
- Troubleshoots national and local payer reimbursement and policy issues
- Provides the most effective communication to health plans to ensure maximum level of reimbursement approval
- Strong understanding of coding, coverage, payment, and reimbursement methodologies in the US health care policy and payment systems, including ambulatory surgery center, hospital outpatient, and physician reimbursement
- Hands on experience with Federal rule making processes
- Familiar with global market access requirements
- Proficiency in presenting evidence and tools in a simplified manner to commercial organizations such as Sales and Marketing
- This includes but not limited to sales education and training, medical education, and national accounts
- Computer literacy (Microsoft Office Suite)
Director of Patient Care Services
Fresh Start Psychiatric Clinic
06.2017 - 11.2021
- Responsible for hiring new staff, negotiating employee benefits, developing personnel policies, resolving labor conflicts, maintaining equipment, ordering medical supplies, ensuring compliance with all government guidelines, guaranteeing medical records are stored properly, completing payroll, preparing taxes, transmitting insurance claims, performing internal compliance audits, and marketing new medical services
- Also handling the business aspects of medicine to maximize physicians' time, decrease patient wait time, and enhance patient care
- Managed two locations with 4 direct reports.
Director of Revenue Cycle Management
Susan E. Uhrich MD & Associates
12.2012 - 03.2022
- Under the supervision of the Executive Director of Business Operations, responsible for assessing, assuring, and implementing business improvements among federally funded Clinic employees and their functional areas in accordance with applicable local, state, federal guidelines and the fiscal and operational policies of the Board
- Responsible for implementing business-related goals and Board/executive priorities and for providing regular progress reports and business assessments to the Executive Officers and Board
- Directed Clinic staff, RCM staff and procedures - Assisted with FQHC operational grant obligations, complaint resolution, and direction of business functions in all clinic services
- Provided business assistance and support to medical staff, with oversight of Patient Services Representatives
- Worked collaboratively with other clinic mangers to assure operational compliance with Board policies and with Local, State and Federal policies, regulations, and laws
- Worked with administrative executive staff to implement related policies and to manage staff; responsible for implementing the required business improvement goals related to finance, human resources, risk, safety, compliance, HIPAA, ADA, IT, purchasing, etc.; Represented organization in the community as assigned
- Managed provider/patient scheduling logistics in compliance with policies and clinic redesign expectations
- Acted as a liaison between the clinics and billing and collections departments to ensure paperwork was completed and business office procedures and appointments were managed according to policy
- Identified areas for potential cost-savings in all aspects of business; participated in the preparation of grant applications; produced all required reports; implemented any business-related JCAHO recommendations; prepared and proposed cost-effective budgets for executive consideration; Directed staff to assure compliance with key fiscal business functions, e.g., billing and collections, coding, medical records management, fee proposals and revisions, Medicare Cost reports, and budgeting
- Coordinated business activities to assure timely processing of all charges, statements, and third-party claims
- Reviewed outstanding Accounts Receivables and made recommendations for further collection activities
- Assisted in addressing building, maintenance, and security issues; and investigated, sought out resolution, and reported outcomes of all business-related patients' complaints in accordance with applicable laws, policies, and executive procedures
- Generated clinic management reports for Executive Officers and/or Board review on monthly and quarterly basis
- Spearheaded business improvement projects including Electronic Medical Records improvements and chart management services; reengineering of the Clinics, and other initiatives established by executive officers and the Board
- Provided progress reports to the Board, QA/QI Team, Executive Director of Fiscal Operation and CEO; developed fiscal and productivity reports including those related to patient service contracts such as Medicaid, HMOs, schools, etc.; and prepared the annual UDS report
- Carried out supervisory responsibilities in accordance with the organization's policies and applicable laws
- Supervised scheduling, grant writing, registration audits, sliding fee discount audits, front desk collections audits, and all other business requirements and functions
- Monitored staff/client ratios, hired and trained employees; planned, assigned, and directing work; appraising performance; disciplining employees; recommending awards for employees; addressing complaints and resolving problems; and other duties as assigned.
Education
Master of Science - Health
University of Louisiana At Monroe
Monroe, LA 05.2008 -
Skills
Grant WritingInternal AuditsProgram management (10 years)Microsoft Office (10 years)Project leadership (8 years)Pharmaceutical sales (6 years)Strategic planning (10 years)Sales (10 years)Team management (10 years)Product Launch Planning (6 years)Healthcare management (10 years)Project leadership (10 years)Documentation ReviewMedical BillingHIPAAMedical CodingMedical RecordsInsurance VerificationCRM software
Client Interviews
Teamwork and Collaboration
New Policies Processing
Data Entry
Prior Authorization Processing
Payment and Investigation Escalations
Regulatory Compliance Adherence
Patient Contact
Great Mathematical Skills
Denied Claims Identification
Data Entry Software
Billing Software
Financial Transactions
Account Management
Critical Thinking
Attention to Detail
Decision-Making
Composing Business Correspondence
Written and Verbal Communication
Caregiver Reimbursement
File Management
Recordkeeping
Cost Reporting
Change Management
Patient Account Reviews
Quality Assurance
Compliance Enforcement
Professional Writing
Data Analysis
P&L Management
Personnel Management
Partnership Development
OSHA Compliance
Systems Optimization
Vendor Relationship Management
Proposal Development
Financial Leadership
Business Development
Procurement
Quality Control
Supply Chain Management
Team Development
Certification
AED Certification
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Quote
Judge a man by his questions rather than his answers.
Voltaire
Timeline
Senior Claims Reimbursement Specialist
United Biosource Corporation
02.2023 - Current
Field Reimbursement Manager
CPSI
07.2021 - 09.2022
Case Manager Supervisor
United Biosource Corporation
06.2021 - Current
Program Manager
United Biosource Corporation
01.2021 - Current
Director of Patient Care Services
Fresh Start Psychiatric Clinic
06.2017 - 11.2021
Director of Revenue Cycle Management
Susan E. Uhrich MD & Associates
12.2012 - 03.2022
Master of Science - Health
University of Louisiana At Monroe
05.2008 -