Summary
Overview
Work History
Education
Skills
Timeline
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Sharon Griffin

Valrico,FL

Summary

Benefits Verification Specialist (BVS) as well as 15 years of Credentialing. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. To seek and maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills. Achievements include completing more than [40] healthcare provider applications each month with no critical errors. Highly organized and detail-oriented with in-depth knowledge of insurance regulations. Hardworking and passionate job seeker with strong organizational skills eager to secure entry-level [Job Title] position. Ready to help team achieve company goals. Self-motivated Benefits Specialist demonstrating superior understanding of employee benefits laws and human resource software systems. Astute professional providing benefits support in fast-paced corporate settings.

Overview

24
24
years of professional experience

Work History

Benefits Verification Specialist

Amgen
05.2023 - Current
  • Benefits Verification Specialist assists in enabling access to progressive therapies that improve health and well being of individuals with treatable diseases
  • This will frequently involve engaging directly with health care professionals to establish options for financial assistance / reimbursement by navigating complex benefits programs and increasingly complicated payer landscape across the United States
  • Of utmost importance are need to engage empathetically with partners and stakeholders (b) self-starting demeanor and desire to problem solve by leveraging lessons learned and best practices, and (c) attention to detail and ability to assure high quality of data integrity when interacting with supporting technologies
  • In depth training will be provided to arm with skills that will make successful in this role
  • Looking for individuals who have the ability to learn and follow standard operating procedures (SOPs)
  • Taking calls and outreach from health care professionals (HCPs) and entering data into supporting systems to initiate enrollment of new and existing patients
  • Initiating benefits verification by reviewing patient data and insurance material, including identifying missing information and following up with points of contact to resolve information gaps
  • Verifying benefits for each assigned patient case and detailing any requirements for reimbursement including copays, coinsurance, utilization management requirements, qualifications / restrictions, and prior authorization requirements
  • As applicable, initiating subsequent actions (e.g
  • Prior authorizations, appeals, travel and appointments)
  • Monitoring potential delays or pended cases, and identifying and documenting lessons learned and potential leading practices resulting in shorter processing times or higher success rates
  • As required, supporting new initiatives and process improvement activities (e.g.
  • End user testing of new system features and supporting technology)
  • Understanding, and adhering to, government regulations and company policies
  • Maintains positive rapport with internal and external customers through effective communication and active listening
  • Able to remain agile with multiple plan designs and call types.

Configuration Analyst

HealthAxis
02.2022 - 03.2023
  • As a Configuration Analyst I have strong analytical and organizational skills, excellent understanding of CMS guidelines for MA’s, PFFS and Medicaid products, configuration and implementation knowledge of Medicare/Medicaid
  • To ensure that the personnel of a facility, mainly healthcare, are properly trained, licensed and certified as mandated by state and federal regulations
  • In addition, must ensure that all services offered by these industries meet standards set by state and federal government agencies
  • As a Credentialing Specialist would review applications, verify both individual and facility accreditation, maintain records of verification and work with auditors as needed
  • Complete verification and maintaining licensure and other information for a healthcare facility
  • Also, I am the intake specialist who assigns tickets to various configuration Analyst from various 6 queues
  • Logging into the configuration’s spreadsheet
  • Checking on tickets closed and inputting on the spreadsheet, as well as closing out tickets and assigning back completed ticket to originator
  • As well as creating tickets

Credentialing Specialist

HealthAxis
04.2018 - 02.2022
  • Completion of health care professionals credentialing and re-credentialing applications
  • Data entry of new applications in credentialing database
  • Maintain working knowledge of the National Committee on Quality Assurance (NCQA) standards and State and Federal regulations related to credentialing
  • Perform and collect PSV (primary source verification) documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on NCQA standards, health plan requirements and company credentialing policies
  • Maintain the credentialing database and ensure up-to-date information is obtained at all times
  • Responsible for monitoring and managing credentialing/re-credentialing requirements and to ensure collection of all required renewal certifications are on file within required time frame
  • Provide consistent and timely follow-up on all outstanding credentialing/re-credentialing files
  • Prepare and scan credentialing/re-credentialing files and other credentialing documentation into scanning software
  • Prepare credential committee grids and any adverse action documentation
  • Answer credentialing telephone line and emails provide support to physicians, physician office staff, health plan contacts and company departments as necessary
  • Process provider demographic changes ensuring appropriate documentation has been submitted with changes, update credentialing database and notify health plans of changes
  • Process provider network terminations, specialty/category changes, Primary source credential verification
  • Knowledge of Medical Licensure process with multiple boards
  • Cross function with other teams and clients for Credentialing questions
  • Enters researched and/or corrected information into credentialing database
  • Contact’s healthcare providers for missing information identified during credentialing process
  • Reviews and organize files for accuracy and completeness in preparation
  • Conducts audits of required documentation for healthcare professionals
  • Verifying legitimacy of practitioner information with universities, licensing agencies, and certification groups

Credentialing Representative

Coast Dental
12.2013 - 03.2018
  • EagleSoft Linkage for Dentists and Hygienist’s, responds to field office request’s for Eaglesoft entries
  • Enters Hygiene and Dentist Providers of service in the billing system upon request
  • Complete follow up on providers’ FL Medicaid Id applications, confirm submissions are in process, responds to request from ACHA for additional information, confirms FL Medicaid ID, and notifies the team within 4 hours of receipt of the ID
  • Send follow up to insurance carriers on providers pending approval for initial credentialing
  • Save Welcome letter, scan, saves, and update Coast Central of Effective dates in spreadsheet with the effective dates
  • Complete follow up on all CMS applications, responds to requests from CMS for additional information, save environment confirmations to dentist’s electronic chart
  • Hardcopy filing of dentists credentialing file once delegated credentialing has been approved by the committee

Claims Examiner/Credentialing Representative

Argus Dental
12.2011 - 07.2013
  • Responsible for servicing customers by processing claims and adjustments accurately and timely within a Contact Center exceeding customer service requirements
  • Served as a training resource and mentor as needed
  • Processes paper claims and electronic work queues, including HCFA 1500 and UB92, in accordance with company policies and procedures
  • Interprets and processes difficult adjustments by company policies and procedures
  • Reviews basic pended claims to determine the appropriateness of the claim status
  • Research customer information by effectively using the 'Essentials' online resource library and Customer Service Console to gather the documentation needed to process claims and adjustments
  • Examines information including, but not limited to authorization denials, coordination of benefits, and eligibility
  • Demonstrates a full understanding of all products
  • Maintains production and claims quality standards
  • Takes responsibility for completing assignments and bringing all outstanding issues to closure
  • Investigates analyzes and resolves outstanding issues to achieve customer satisfaction; uses a systematic approach to payment issues through analysis and evaluation of information and alternate solutions
  • Work independently and manage own activities and minimal supervision and direction to meet customer needs.

Pre-Authorization Representative

Coventry Health
07.2008 - 07.2013
  • Performs telephonic support for the online authorization of routine services
  • Provides direct support to primary care practices and specialty care providers regarding utilization, authorization, and referral activities
  • Proficient in the use of ICD-9 and CPT codes
  • Data entry of referrals for non-complex services including DME, physical therapy, inpatient and outpatient care, behavioral health services, and testing as applicable, and special circumstance requests as defined by Utilization Management
  • Assists in gathering information needed for coordinators/case managers to determine authorization
  • Provides data entry for care that has been arranged by the Pre-Authorization Coordinators
  • Contacts providers with authorization, denial, and appeals process information
  • Assists in educating and acts as a resource to primary care practices and specialty care providers
  • Verifies eligibility of members and participating status of providers in IDX
  • Determines member benefit coverage utilizing IDX or group coverage documents
  • May receive pended claims reports on claims received without prior authorization to research and review eligibility and benefit coverage
  • Upon the decision of claim payment status, generates the appropriate referral with notification and exchange of information to the service organization for proper adjudication of claim payment
  • Assists with the identification and reporting of potential quality management issues
  • Responsible for ensuring these issues are reported to the Quality Management Department.

Technical Claims Specialist

Coventry Health
04.2004 - 06.2009
  • Responsible for servicing customers by processing claims and adjustments accurately and timely within a Contact Center exceeding customer service requirements
  • Service as a training resource and mentor as needed
  • Processes paper claims and electronic work queues, including HCFA 1500 and UB92, by company policies and procedures
  • Interprets and processes difficult adjustments by company policies and procedures
  • Reviews basic pended claims to determine the appropriateness of the claim status
  • Research customer information by effectively using the 'Essentials' online resource library and Customer Service Console to gather the documentation needed to process claims and adjustments
  • Examines information including, but not limited to authorization denials, coordination of benefits, and eligibility
  • Demonstrates a full understanding of all products
  • Maintains production and claims quality standards
  • Takes responsibility for completing assignments and bringing all outstanding issues to closure
  • Investigates analyzes and resolves outstanding issues to achieve customer satisfaction; uses a systematic approach to payment issues through analysis and evaluation of information and alternate solutions
  • Work independently and manages own activities and minimal supervision and direction to meet customer need
  • Guide Provider Relations Representatives to ensure prompt resolution to provider issues involving incorrect claim payments
  • Maintain accurate and current provider databases relating to provider facilities and physician information
  • Provide support for payer data, leasing, and remote re-pricing clients and payers for rate
  • Resolves technical issues to ensure claims such as EPO, PPO, HMO, and Medicare claims are priced accurately
  • Research pricing issues referred from internal departments for claims that were previously priced by payer data, leasing, and/or remote re-pricing clients
  • Refers the issue to the client for adjustment, and may follow up to verify corrections are complete
  • Act as the liaison with internal departments to handle PPO, HMO, Medicaid, and Medicare Provider issues
  • Assists Customer Service contacts with complex issues that require in-depth knowledge to resolve and assist with a resolution regarding claims issues where needed.

Pre-Authorization Coordinator

Gentiva Health Services
12.1999 - 06.2004
  • Responsible for benefits interpretation and managing Authorization, pre-authorization, Health Benefit coverage for Home Health Care, Medicare/Medicaid claims in addition to CareCentrix
  • Contact Various Insurance Agency’s benefits departments to verify benefits (multi-state) ensuring services provided are covered to include effective dates, limitations, preexisting, deductible, and co-payment
  • Complete eligibility and benefit verifications to ensure that member/patient has coverage under CareCentrix accounts Cigna and Greatwest
  • Decide based on eligibility coverage to establish a primary payer
  • Correspond with Nurse Case Managers regarding provider networking, pre-certification, Reauthorization and submitting clinical followed by utilizing the tickler system for pending authorizations.

Education

Associate degree - Healthcare Administration

Argosy University
Tampa, FL

Medical Administration

Hillsborough Community College
Tampa, FL

Skills

  • Extensive knowledge of PPO, HMO Medicare, and Medicaid Managed care policies
  • Proficient in Microsoft Office applications, including Microsoft Excel
  • Strong analytical and problem-solving abilities
  • Excellent analytical and organizational skills
  • Customer Service
  • Data Entry
  • Configuration Analyst
  • Claims Pend reports
  • Verification of Benefits
  • Special Projects
  • Healthcare regulations

Timeline

Benefits Verification Specialist

Amgen
05.2023 - Current

Configuration Analyst

HealthAxis
02.2022 - 03.2023

Credentialing Specialist

HealthAxis
04.2018 - 02.2022

Credentialing Representative

Coast Dental
12.2013 - 03.2018

Claims Examiner/Credentialing Representative

Argus Dental
12.2011 - 07.2013

Pre-Authorization Representative

Coventry Health
07.2008 - 07.2013

Technical Claims Specialist

Coventry Health
04.2004 - 06.2009

Pre-Authorization Coordinator

Gentiva Health Services
12.1999 - 06.2004

Associate degree - Healthcare Administration

Argosy University

Medical Administration

Hillsborough Community College

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Sharon Griffin