Shannon Greene
Baltimore,MD
Summary
A self-motivated administrative professional seeking a position in a challenging environment. Over 10 years’ experience successfully providing administrative, customer service and claims processing to the healthcare industry. Proficient in a range of computer applications. Well developed communication skills. Proven ability to efficiently plan and manage multiple assignments to meet deadlines. A proactive problem solver who gets the job done.
Overview
18
18
years of professional experience
Work History
Provider Relations Advocate
UnitedHealth Group
Baltimore, MD
06.2023 - Current
- Facilitated the onboarding process for new providers, including verifying credentialing information and contracting.
- Use pertinent data and facts to identify and solve a range of problems within area of expertise.
- Investigates non-standard requests and problems, with some assistance from other departments.
- Prioritizes and organizes own work to meet deadlines.
- Conducted outreach activities to engage providers in network development initiatives.
- Assist in efforts to enhance ease of use of physicians' portal and future services enhancements.
- Help implement training and development of external providers through education programs.
- Support development and management of provider networks.
- Contribute to the design and implementation of programs that build/nurture positive relationships between the health plan, providers, and practice managers.
- Participated in training sessions with other departments within the organization on topics related to provider relations.
- Maintained positive working relationship with fellow staff and management.
- Displayed strong telephone etiquette, effectively handling difficult calls.
- Utilized document management system to organize company files, keeping up-to-date and easily accessible data.
MEDICAL CARE PROGRAM SPECIALIST 2
Maryland Department of Health
Baltimore, MD
03.2017 - 05.2023
- Provide complex administrative support to the Provider Resolutions Unit for Maryland Medicaid Medical Assistance Program
- Apply and interpret Medical Assistance regulations and policy regarding fee for service for professional services covered by the provider
- Resolve and process complex problem claims/cases related to recipient eligibility and claim errors.
- Provide liaison services to the various Maryland Department of Health (MDH) and the Department of Health Services (DHS) administrations, home health and professional services provider community with issues related to claims, eligibility, policy and payments.
- Serve as a call center representative primary information resource for Medicaid providers and its fiscal representatives that make inquiries and register complaints regarding policy and procedure effecting payment of claims
- Responsible for the accurate and timely adjudication of Primary and Secondary and Third-Party claims for fee for service professional providers
- Interpret and Review Medicare and Commercial EOBS to determine co-insurance and or deductible amount to be paid, while following CMS Guidelines
- Review and interpret benefits edit/audit resolution, claim payment and routing claims to Policy/Appeals for resolution
- Follow all state and federal guidelines while determining responsible payer
- Review Appeal letters/request from providers to determine payable procedure codes and or recipient/provider eligibility
- Assist providers with credentialing and enrollment issue
- Perform various administrative functions using the following systems Microsoft Suite, Google Suite and the Maryland Medicaid Management System (MMIS)
MEDICAL CARE PROGRAM ASSOCIATE 2,
(MCHP) Maryland Department of Health
Baltimore, MD
12.2014 - 03.2017
- Review Cares and Maryland Health Connections referrals to determine category of eligibility by interpreting and applying program policies and procedures for enrollment into the MCHP Program.
- Maintain care records files, reports, and program data.
- Assist client in resolving any issues, problems, and concerns regarding Case.
- Provide liaison services to healthcare providers and health agencies.
- Answer all incoming calls in accordance with Program policies and procedures, and provide responses to client inquiries.
- Maintain ongoing contact with assigned caseload clients, DHMH staff, and external sources for resolution of case management issues.
- Responsible for case record activities, including initial client/case file set up: review of referral documentation, upon eligibility determination, establish accounts in the Accounts Receivable system, and initiate Health Choice enrollment package.
- Maintain client information in MMIS either through client contact or upon referral report and resolving and resolving client/case problem and issues.
- Perform redetermination and case closure activities as deemed necessary
- Train new hires
PHARMACY CALL CENTER SPECIALIST 2
Cigna-HealthSpring
Baltimore, MD
01.2010 - 10.2013
- Aids assistance to Medicare and Medicaid members and providers requesting coverage determination, appeals for medication requests via telephone, fax, and voicemail.
- Assist retail, long-term care and hospital pharmacies with processing claims, rejections codes and refill overrides using claims system
- Log, collect, and compile coverage determination requests into the pharmacy database.
- Conduct outbound calls to providers to collect any additional clinical information needed for review of coverage determinations, according to scripts, tools, and protocols, meeting both productivity and performance expectations.
- Conduct all calls in a courteous and customer service-friendly manner.
- Compile monthly spreadsheets for GPI Formulary Update, Medi-Span Drug Updates, and FDA drug shortage list.
- Protect member PHI (Protected Health Information)
- Perform mathematical calculations to determine drug dosages.
- Traveled out of state to train counterparts in Nashville.
- Train new hires on proper protocol for processing coverage determinations.
- Serving as a liaison on the Pharmacy Explorations Development Council, assisting with the composition of the biweekly department newsletter containing SOPs' auditing criteria for reviews, compliance awareness, and CMS audit readiness.
CERTIFIED PHARMACY TECHNICIAN
Target Pharmacy
Baltimore, Maryland
09.2006 - 06.2009
- Provided medication and other healthcare products to customers accurately and efficiently.
- Assisted pharmacists in preparing prescriptions for filling, including counting tablets and labeling bottles.
- Verified accuracy of patient information on prescription orders.
- Maintained pharmacy inventory by restocking shelves with medications and supplies.
- Received verbal prescriptions from physicians or nurse practitioners via telephone, fax or electronic means.
- Processed third-party insurance claims for reimbursement of pharmaceuticals.
- Performed administrative duties such as filing, data entry, answering phones.
Education
Some College (No Degree) - General Studies
CCBC
Baltimore, MDSkills
Excellent customer service skills
Proficient in Microsoft Office programs
Professionalism and strong work ethic
Excellent time management skills
Excellent problem-solving skills
Great communication skills
Timeline
Provider Relations Advocate
UnitedHealth Group
06.2023 - Current
MEDICAL CARE PROGRAM SPECIALIST 2
Maryland Department of Health
03.2017 - 05.2023
MEDICAL CARE PROGRAM ASSOCIATE 2,
(MCHP) Maryland Department of Health
12.2014 - 03.2017
PHARMACY CALL CENTER SPECIALIST 2
Cigna-HealthSpring
01.2010 - 10.2013
CERTIFIED PHARMACY TECHNICIAN
Target Pharmacy
09.2006 - 06.2009
Some College (No Degree) - General Studies
CCBC