Shemika Shaw-Williams
Dallas,Texas
Summary
Experienced patient account representative bringing several years experience in medical collections including resolving patient balances and reducing outstanding receivable. Well-developed communication, time management and problem-solving abilities.
Overview
15
15
years of professional experience
Work History
Patient Account Representative
Guidehouse
Lewisville, TX
10.2024 - Current
- Contacts third party payers and guarantors via payer websites or by phone to resolve account balances on all assigned accounts.
- Work all correspondence within 24 hours or receipt. Detail notes regarding correspondence must be entered into the client’s system
- Works all denials taking necessary actions to obtain account resolution
- Submits appeals, as appropriate, for all non-clinical denials
- Monitors all denials for trends and issues and reports findings to supervisor
- Bills or re-bills claims as necessary
- Ensures the client follows all state and federal rules and regulations both billing and HIPAA
- Completes assigned special projects within the time frames given
- Appropriately documents each account worked in client practice management system
- Makes corrections in client practice management system.
- Updates patient accounts with corrected demographic or insurance information
- Posts adjustments based on standard operating procedures or as directed by leadership
Insurance Verification Specialist
Medix Infusion
Addison, Tx
12.2022 - 10.2024
- Followed up on unpaid claims and patient balances to ensure timely collections.
- Contacted patients to resolve outstanding balances and discuss financial options.
- Verifies health insurance coverage and benefits for assigned payers etc., Blue Cross Blue Shield, Commercial, Worker’s Compensation, and Government/State insurance plans and determines patient’s responsibility via phone, fax, or payer portals
- Provide timely completion of insurance review for established patients
- Documents timely and accurately in the EMR system
- Reviews payor medical policies to determine medical necessity and/or FDA guidelines including Medicare billing and coding guidelines
- Coordinates with medical providers in obtaining necessary documentation to support medical necessity
- Submits appeal request to payers for denied authorizations and follows-up on timely turnaround
- Obtains authorization for infusion services for established patients
- Knowledge of reimbursement policies
- Complete follow-up tasks as assigned
- Assures work is completed in a timely manner to prevent delays in patient care
- Attends departmental meetings and in-services as requested.
Financial Services Intake Coordinator
Advance Infusion Solutions
Dallas, TX
11.2020 - 10.2022
- Managed collections for infusion services by contacting patients and insurance for outstanding balances.
- Collaborated with billing and collections team to track and reduce aging accounts receivable.
- Verifies health insurance coverage and benefits for assigned payers etc., Blue Cross Blue Shield, Commercial, Worker’s Compensation, and Government/State insurance plans and determines patient’s responsibility
- Enter insurance information into CPR+ and notify home office of any IV or high dollar drug and of coverage and benefits
- Teleconference with patient and providers and conduct the initial adherence call
- Advise patients and caregivers of financial obligations and copayments
- Determines if pre-certification or prior authorization is required from insurance company
- Documents, in detail, phone calls, phone number, person spoken to and call details on a consistent basis
- Investigate and verify benefits for pharmacy and medical third-party claims for assigned cases
- Communicate with financial assistance team of drug manufacturers to apply for and secure financial assistance for patient when assigned
- Maintains a thorough understanding of NDC (National Drug Code) numbers, billing units, metric quantities etc
- Maintains a broad range of knowledge of insurance plans, medical terminology, billing procedures, government regulations and medical codes
- Obtain prior authorizations; initiate requests, follow up to provide additionally required information, track progress, and expedite responses from insurance carriers and other payers and maintain contact with customers to keep them continuously informed
- Review for accuracy of prescribed treatment regimen prior to submission of authorization
- Facilitate appeals process between the patient, physician, and insurance company by requesting
- Composes clinical appeals letters based off specific denial reason and patients’ clinical presentation
- Ensures all clinical information and documentation are obtained prior to appeal submission
- Coordinates appointment of representative documents with patient and physician office.
Patient Access Coordinator
Kroger Specialty Infusion Pharmacy
Richardson, TX
08.2019 - 11.2020
- Assisted in resolving billing discrepancies and initiated follow-up on overdue payments.
- Educated patients on financial responsibilities and payment options
- Notify patients when their prescriptions have been transferred and follow up
- Teleconference with patient and providers and conduct the initial adherence call
- Advise patients and caregivers of financial obligations and copayments
- Develop documentation to standardize workflow process changes
- Facilitate warm transfers to manufacturer Hubs when required
- Investigate and verify benefits for pharmacy and medical third-party claims for assigned cases
- Communicate with financial assistance team of drug manufacturers to apply for and secure financial assistance for patients when assigned
- Obtain prior authorizations; initiate requests, follow up to provide additionally required information, track progress, and expedite responses from insurance carriers and other payers and maintain contact with customers to keep them continuously informed
- Review for accuracy of prescribed treatment regimen prior to submission of authorization
- Facilitate appeals process between the patient, physician, and insurance company by requesting
- Composes clinical appeals letters based off of specific denial reasons and patients’ clinical presentation
- Ensures all clinical information and documentation are obtained prior to appeal submission
- Coordinates appointment of representative documents with patient and physician office.
Insurance Verification Specialist
Alliance Rx Walgreens Prime
Irving, TX
10.2017 - 08.2019
- Utilize all available resources to obtain and enter insurance coverage information for ordered services into patient's file
- Verify patient insurance coverage of medications, administration supplies and related pharmacy services through proper investigation into either major medical benefits (including Medicare) or pharmacy benefits
- Completes the prior authorization process with insurance companies and practitioner offices
- Complete a full Medical Verification for all medications, administration supplies and related pharmacy services
- Notify patients, physicians, practitioners and/or clinics of any financial responsibility of services provided and requested services that are not provided by the facility
- Facilitate pharmacy and major medical claims with insurance companies and practitioner offices and investigate and facilitates prior authorization and any other claim rejections
- Provide notification of urgent orders to the Group Supervisor and communicates with other departments when an urgent need for filling a prescription or delivery is necessary
- Place outbound calls to patients or physicians' offices to obtain additional information needed to process the script or to notify of delay in processing script
- Manage inbound calls on the Insurance line from patients, clients, physicians, practitioners, and clinics regarding inquiries about services provided, financial responsibility and insurance coverage.
Pharmacy Care Coordinator
Amerisource Bergen Specialty Pharmacy
Frisco, TX
12.2015 - 10.2017
- Provide intake services and setup for all new patients
- Verify benefits on both pharmacy and major medical plan
- Review clinical documents for prior authorization/ pre-certification submission purposes
- Initiate, complete (when allowable) and tirelessly pursue Prior Authorization approval from insurance carriers and offer to go above and beyond to assist and support our MDO practices whenever possible
- Coordinates the patient's care with physician offices, nurses, pharmacists and patients
- Performs accurate and timely insurance verification, both major medical and pharmacy benefits
- Coordinates prescription deliveries and refills for patients
- Works with home health nursing visits and maintenance of a patient census throughout the course of their therapy
- Supports other team members in the healthcare team
- Ensures a continuous quality improvement customer service approach by proactively identifying areas of improvement and communicating those ideas to the healthcare team
- Maintains current documentation related to the patient’s drug therapy and pharmacy care plan
- Flag issues that need to be addressed
- Coordinates responses and resolutions to issues with appropriate internal and external parties
- Nurture/foster strong supporting relationship with every physician's office
- Actively participates in roundtable discussions with Pharmacists, Nursing Services and Pharmacy Care Coordinators to review cases and related drug therapy and pharmacy care plan issues
- Maintains and promotes positive and professional working relationships with associates and management
- Performs related duties as assigned.
Pharmacy Service Agent
DaVita Rx Pharmacy
Coppell, TX
12.2012 - 12.2015
- Answer telephone inquiries, referring callers to the pharmacist when necessary
- Process medical insurance claims, posting bill amounts and calculating copayments
- Receive, store, and inventory pharmaceutical supplies or medications, check for outdated medications, and notify pharmacists when inventory levels are low
- Provide customers with information about the uses, effects, and interactions of drugs and out of stock items
- Receive written prescription or refill requests and verify that information is complete and accurate
- Establish or maintain patient profiles, including lists of medications taken by individual patients
- Answer telephones, responding to questions or requests
- Assist customers by answering simple questions, locating items, or referring them to the pharmacist for medication information.
Customer Service Agent
Bravo Health Insurance
Irving, TX
11.2010 - 03.2012
- Review insurance policy to determine coverage
- Prepare insurance claim forms or related documents and review them for completeness
- Provide customer service, such as limited instructions on proceeding with claims or referrals to auto repair facilities or local contractors
- Pay small claims
- Transmit claims for payment or further investigation
- Calculate amount of claim
- Review insurance policy to determine coverage.
Education
High School Diploma -
H. GRADY SPRUCE
Dallas, TXDiploma - Business Administration in Technology
ATI Career Training Center - Dallas
Dallas, TXDiploma - Medical Office Assistance
PCI Health Training Center - Richardson
Richardson, TXSkills
- ICD-10/CPT codingns
- Accounts Receivable
- Payment Posting
- Patient Financial Counseling
- Collections & Follow-up
- ICD-10/CPT Coding
- Office Manager
- CMS 1500
- HIPAA
- File Clerk
- Bookkeeping
- OSHA
- Insurance Claims
- Billing
- MediSoft
- Scheduling
- Accounting
- UB92
- Medical Terminology
- Microsoft Office
- NaviNet
- Script me
- Availity
- One Health Port
- J Codes
- Teams
- Zirmed(waystar)
- Lynx
- Exponent HR
- Carecentrix
- CPR
- Wellmed
Timeline
Patient Account Representative
Guidehouse
10.2024 - Current
Insurance Verification Specialist
Medix Infusion
12.2022 - 10.2024
Financial Services Intake Coordinator
Advance Infusion Solutions
11.2020 - 10.2022
Patient Access Coordinator
Kroger Specialty Infusion Pharmacy
08.2019 - 11.2020
Insurance Verification Specialist
Alliance Rx Walgreens Prime
10.2017 - 08.2019
Pharmacy Care Coordinator
Amerisource Bergen Specialty Pharmacy
12.2015 - 10.2017
Pharmacy Service Agent
DaVita Rx Pharmacy
12.2012 - 12.2015
Customer Service Agent
Bravo Health Insurance
11.2010 - 03.2012
High School Diploma -
H. GRADY SPRUCE
Diploma - Business Administration in Technology
ATI Career Training Center - Dallas
Diploma - Medical Office Assistance
PCI Health Training Center - Richardson
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