Quinta Hilsman

•Assess individual patients' access needs and develop an action plan that provides for the

initiation and continuation of treatment.

•Help facilitate insurance approval for Rare Disease therapies.

•Educate patients, caregivers, health care providers, and others regarding insurance options,

requirements or limitations, case management services, and steps needed to gain product and

administration approval.

•Maintain comprehensive understanding of the reimbursement process, navigation of health

care systems, billing/coding guidelines, insurance plans, payer trends, internal and external

patient assistance programs, and related resources.

•Enroll patients who qualify into the appropriate financial assistance program as

needed/required.

•Consistently maintain and document accurate data, including insurance, coverage approvals,

on-going coverage requirements, and all patient and provider interaction

•Provide caseload coverage outside of assigned territory as needed.

•Respond to inbound inquiries from providers, medical office staff, and payers by phone, email,

and internal messaging

•Support providers with real-time order status updates, prescription processing steps, and plan-

specific requirements

•Triage escalations and resolve urgent or complex order-level issues efficiently

•Clearly communicate program requirements, expected copays, and processing timelines

•Coordinate with internal partners and external pharmacy networks to remove order bottlenecks

•Guide provider teams through billing issues, prior authorizations, tier exceptions, and appeals

•Use professionalism, de-escalation and active listening skills to manage provider frustrations and

keep communication productive

•Log updates across internal systems accurately and on time

•Identify common workflow issues and share insights to improve team processes

Superb written documentation of services provided in all cross-functional systems

Accurately post insurance and patient payments, adjustments, and claim denials into the billing

system.

•Review and reconcile Explanation of Benefits (EOBs) and Electronic Remittance Advices (ERAs).

•Billing queue regularly to review and respond to member inquiries, providing timely and

accurate assistance with billing-related questions.

•Uploading and reconciling 835 files across multiple sources

•Follow up on outstanding insurance claims and patient balances.

•Conduct collection activities, including contacting patients regarding balances, establishing

payment arrangements, and updating accounts.

•Work with insurance carriers to resolve denied or underpaid claims.

•Run patient AR reports to post any open balance.

•Maintain accurate and up-to-date records of all patient billing activities.

•Supports the authorization, monitoring and the processing of claims for inpatient and outpatient

services by entering data into designated system and triaging events per department

guidelines.

•Maintains data entry requirements by following established workflows and departmental

policies and procedures.

•Verifies member data by researching eligibility, member participation in Care Management

Programs, benefits, network provider status, contracts and division of financial responsibility

(DOFR).

•Maintains telephone standards by answering calls within established turnaround times.

•Communicates effectively with members by providing appropriate and timely information and

by showing courtesy and respect each member, their caregivers and/or representatives.

•Route calls and cases to appropriate medical management teams (e.g., nurses, case

managers, utilization review).