Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

SUMERA GHANI

Palatine,IL

Summary

Over 11 years of experience in Pharmacy claim PBM. Worked with multiple insurances payers to provide customer infusion care. Supported Medicare/Medicaid/HMO, Commercials and Governments claims and billing, handled many adjudication cases reviews. Skilled in Intake verification of eligibility, processing benefits and handling customer infusion drugs cases for authorization. Familiarity with patient drug rejections and monitoring the cases. Experienced NCPDP Claims Authorizations Analyst, passionate, believes in facilitating wellness of the patient. Over 9 years of experience in Health Care Analytics.

Overview

25
25
years of professional experience
1
1
Certification

Work History

Sr Complex Billing Analyst

ASPN Pharmacutical
03.2023 - Current
  • Collaborating with senior management working on Abbvie Botox Projects and working others biological drugs .
  • Coordinate with neurologist and assist gathering all supporting information related to approval for Botox by FDA guide lien .
  • Working with Abbvie RBA state by state to assist and provided all information related to Migraine drug criteria .
  • Providing excellent service to Botox RBA 3rd party insurances and follow-through of insurance-related issues.
  • Woking on varias insurance included Government , Commerical , VA and all others 3rd party insurance nationwide.
  • Maintaining HICPIC , Producer codes and CPT codes prior authorization reimbursement processes, prior authorization and appeal filings through payers .
  • Understanding BOTOX all Medical and PBM policies approved by FDA and CMS guidelines .
  • Collaborated with cross-functional teams to identify opportunities for process improvement and increased efficiency.
  • Identified and resolved problems through root cause analysis and research.
  • Resolves insurance-related issues and assists patients with various forms of financial assistance
  • Communicates directly with patients over the phone to assist them in the awareness of their medications
  • Maintained strict confidentiality with all personal data as per company guidelines.
  • Maintained up-to-date knowledge of industry regulations, ensuring compliance in all aspects of the billing process.
  • Identified key areas not performing well and implemented effective, new processes.
  • Monitored ongoing project performance closely, making adjustments as needed to ensure timely completion of milestones.

Infusion Drugs Authorization Analyst. Team Lead

Option Care Health
10.2017 - 02.2023
  • Verifying health insurance coverage from contracted payer's Commercial, Medicare, and Medicaid plans
  • Audit PBM infusion and medical claims Prior Authorizations, appeal specialty drugs all to ensure correct coverage of patient procedures and reimbursements
  • Collects and reviews all patient insurance benefit information, to the degree authorized by the SOP of the program
  • Acquire specific CPT's, HCPCS and ICD-10 codes to ensure proper billing
  • Oversee patients' benefits and ensure that proper prior authorization and re-authorization is obtained for additional treatment
  • Coordinate Incoming Referrals and medical records with Clinician Technical Specialist and hospital staff
  • Provides assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications
  • Prepared detailed reports on updates to project specifications, progress, identified conflicts and team activities
  • Completes and submits all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third-party payors
  • Vast knowledge of specialty medication especially Core and IVIG
  • Minimized resource and time losses by Researches and resolves any claim denials or underpayment of claims
  • Worked closely with Provider Relations to enhance Provider relationships through claims analysis and education to the providers on correct billing techniques
  • Collaborated with cross-functional teams to identify opportunities for process improvement and increased efficiency.
  • Validated results and performed quality assurance to assess accuracy of data.
  • Improved internal knowledge sharing by developing comprehensive documentation outlining standard operating procedures for various tasks.
  • Identified and resolved problems through root cause analysis and research.

Medicare Part D claims Specialist Team Lead PBM

Freedom/Optimum Health Plan Medicare / Global TPA/ Anthem
03.2012 - 07.2017
  • Compiled CD and appeal cases, approval, and denial development Medicare Part D benefits
  • Administered and if rejected processed real time claims and ensured utilization
  • Conducted monthly EOB audit program, reviewed denials on case basis
  • Provide details information and assist with implementation of 'Patient Assistance Program' to patients
  • Managed customer issues and adjudicated NCPDP claims for pharmacy billing and Prior authorization
  • In-depth knowledge of managing Part D drugs benefits steps and Training
  • Maintains accurate and current records as required by state and federal law
  • Handling MTM (Medication Therapy Management) Calls and coordinating with Pharmacists
  • Making decision followed by CMS Guideline and time frame
  • Conducted thorough property investigations to identify and classify damages for customer claims
  • Identified insurance coverage limitations with thorough examinations of claims documentation and related records
  • Setup and implemented all formulary and non-formulary drugs coordinate with IT and testing all claims to get appropriate copay and rejection codes setup by CMS guideline
  • Enhanced customer satisfaction with timely communication, empathy, and clear explanations of claim outcomes.
  • Managed a high volume of claims effectively by prioritizing tasks and maintaining excellent organizational skills.
  • Escalated files with significant indemnity exposure to supervisor for further investigation.

Registered Pharmacy Technician

CVS Pharmacy
07.2007 - 08.2011
  • Retrieved and processed customer prescription orders and referrals
  • Consulted with insurance company representatives to complete claims processing, resolve concerns and reconcile payments
  • Communicated with patients to collect information about prescriptions and medical conditions or arrange consultations with pharmacists
  • Achieved high performance evaluations for call handling ability and quality of services provided to patients in a fast paced, high volume call center
  • Build and maintains positive relationships with coworkers and other internal departments and external entities while understanding the importance of dealing with confidential information
  • Contact physicians' offices for refills or continued prescriptions where permitted
  • Maintain complete and accurate dispensing records
  • Maintaining customer records by updating account information
  • Reviewed and verified customer information and insurance provider information
  • Answered incoming phone calls and addressed questions from customers and healthcare providers
  • Coordinated with insurance representatives to process claims and calculate correct co-pay information for patients
  • Prepare Rx aging report for all the departments
  • Recognized and utilized as subject matter expert and resource to others
  • Work on special projects and assumes functional responsibility for project completion
  • Performed wide range of pharmacy operations with strong commitment to accuracy, efficiency, and service quality.
  • Utilized advanced computer systems for prescription processing tasks such as inputting orders, updating patient profiles, and generating labels accurately.
  • Demonstrated strong attention to detail when preparing customized compound medications per pharmacist instructions meeting the unique needs of individual patients.
  • Served as a liaison between pharmacists and nursing staff in hospital settings ensuring accurate medication administration to patients.

Credit Analyst

Union Bank LTD
02.1999 - 01.2005
  • Provided range of application availability reporting to ensure that agreed levels of availability are measured and monitored
  • Ensured shortfalls in application availability are recognized appropriate corrective actions are identified as professed
  • Worked closely with Release analysts
  • Reviewed releases and assigned appropriate release testing tasks
  • Complied and reviewed testing deliverable
  • Conducted presentations to upper management and executive teams for loan recommendations
  • Assessed credit risk and analyzed financial statements.

Education

Bachelor of Science - Healthcare Management and Informatics

Colorado Technical University
Colorado Springs, CO

Bachelor of Arts - Economics

University of Karachi

Skills

  • Production Monitoring
  • Key performance indicators
  • Performance improvement
  • Quality control, Safety processes and procedures
  • Complaint resolution
  • Complied and reviewed, Testing Deliverable
  • Claims review
  • Claims submissions
  • HIPAA Compliance
  • Insurance Verification
  • Data entry proficiency
  • Medical coding knowledge
  • Customer Service
  • Skilled in A1 connect software
  • Reference point, Adobe PDF and EPIC (basic)
  • JIRA, Service Now
  • Confluence
  • Window XP (SP3), Vista 7 & 10 (32bit and 64bit)
  • Microsoft Word, Excel, PowerPoint, Outlook Express
  • Medical software CPR, Informed RX, Citrix
  • All Script, Share Point, One Source for patient Eligibilities
  • Change Health care, One Source and other EMR program
  • Veeva Vault

Certification

  • Registered Pharmacy Technician, IL board of Pharmacy, Active
  • Registered Pharmacy Technician, Florida Board of Pharmacy, Active

Timeline

Sr Complex Billing Analyst

ASPN Pharmacutical
03.2023 - Current

Infusion Drugs Authorization Analyst. Team Lead

Option Care Health
10.2017 - 02.2023

Medicare Part D claims Specialist Team Lead PBM

Freedom/Optimum Health Plan Medicare / Global TPA/ Anthem
03.2012 - 07.2017

Registered Pharmacy Technician

CVS Pharmacy
07.2007 - 08.2011

Credit Analyst

Union Bank LTD
02.1999 - 01.2005

Bachelor of Science - Healthcare Management and Informatics

Colorado Technical University

Bachelor of Arts - Economics

University of Karachi

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SUMERA GHANI