Shannon Leach
Knightdale,NC
Summary
Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures.
Overview
10
10
years of professional experience
Work History
Provider Coordinator Dispute
AmeriHealth Caritas
01.2023 - 06.2024
- Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals
- Determine eligibility, benefits, and prior activity related to the claims, payment, or service in question
- Provide written acknowledgment of member and provider correspondence
- Conduct thorough investigations of all members and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities
- Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination
- Monitor daily and weekly pending reports and personal worklists, ensuring internal & regulatory timeframes are met
- Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved following established policies and procedures
- Resolved customer complaints in a timely manner while upholding company standards.
- Created and maintained accurate records of departmental activities, including budgets, personnel documents and project timelines.
- Facilitated communication between different departments in order to resolve issues quickly.
- Managed day-to-day operations of the department including scheduling tasks and assigning duties.
Case Manager
McKesson Pharmacy
10.2022 - 12.2023
- Demonstrate my ability to work under pressure, communicate effectively, and handle case assignments and patient care coordination
- Claims, billing, and reimbursement
- Investigate benefits for physicians
- Handled prior authorizations with different medical payers including Medicaid, Tricare, Medicare Advantage, Aetna, BCBS, UHC, Carolyn, Caremark, etc
- Approve patients for financial assistance for oncology medications
Benefit Verification Specialist
Lab Corp
08.2022 - 03.2022
- Processed and monitored medication claims
- Analyzed patients’ insurance policies for medication payment and achieved 100% detailed proficiency in multiple information systems
- Assisted Patients and providers with the insurance prior authorization process and updates while maintaining full compliance with HIPPA guidelines
- Explained the requirements for obtaining pre-authorization from insurers.
- Collaborated with medical staff to ensure accuracy of patient records and eligibility for services.
- Reviewed and verified health insurance benefits for patients prior to their scheduled appointments.
- Facilitated communication between providers and payers when there were disputes over claim payments.
- Processed requests from physicians' offices for pre-authorization of tests or treatments.
- Attended training sessions regularly in order to stay up-to-date on industry trends.
- Conducted data entry into relevant systems regarding benefit verifications.
- Worked closely with internal teams to ensure compliance with state and federal regulations governing healthcare benefits verification processes.
- Managed correspondence between patients, providers, and payers regarding authorization status.
- Developed strategies to maximize available coverage for clients.
Pharmacy Service Representative
CVS Specialty
12.2014 - 03.2022
- Answering telephonic customer inquiries in a courteous, friendly, and professional manner using prescribed procedures and scripts
- Researching and resolving inquiries to ensure customer satisfaction and listening attentively, understanding needs and patients' concerns
- Transfer calls to the appropriate party when needed if a question or concern is outside of the scope of CSR
- Achieving over 95% customer satisfaction on all call surveys
- Travel and train newly hired employees
- Assisted team lead/Supervisor with a review of voicemails left due to high call volume
- Developed policies and procedures relating to pharmacy services delivery processes.
- Provided excellent customer service to patients and healthcare providers while answering inquiries, resolving complaints, and processing orders.
- Conducted quality assurance checks on each order before shipping it out.
- Maintained patient profiles, including demographics, insurance coverage, and medication history.
- Facilitated communications between healthcare providers and pharmacists to meet customers' needs.
- Answered customer questions and referred to pharmacist for medication information.
- Processed incoming and outgoing calls regarding prescription refills, adverse reactions to medications, or medical problems related to drugs.
- Analyzed customer needs based on interactions through phone or email correspondence.
Education
Diploma - Medical Assistant
Gwinnett College
North Carolina 01.2011
Highschool Diploma -
Garner Senior
01.2004
Skills
- Data Entry
- Customer Service
- Insurance Verification
- Medical Terminology
- Medical Billing
- Presenting Ideas and Plans
- Medical Billing Processing
- Goal Setting
- Motivational Leadership
- Leadership Development
- Phone and Email Etiquette
- Time management abilities
- Relationship Building
- Claims Processing
- HIPAA Compliance
- ICD-10 Proficiency
- Medical Coding Ethics
- Denial Management
- Pharmacology knowledge
- CPT coding knowledge
- Clinical Documentation
- Patient data identification
- Training and mentoring
Timeline
Provider Coordinator Dispute
AmeriHealth Caritas
01.2023 - 06.2024
Case Manager
McKesson Pharmacy
10.2022 - 12.2023
Benefit Verification Specialist
Lab Corp
08.2022 - 03.2022
Pharmacy Service Representative
CVS Specialty
12.2014 - 03.2022
Diploma - Medical Assistant
Gwinnett College
Highschool Diploma -
Garner Senior
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