Tammie Jackson

• Verified eligibility and compliance with authorization requirements for service providers.
• Tracked referral submission during facilitation of prior authorization issuance.
• Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
• Triaged unscheduled and emergency authorizations, directing submissions to appropriate personnel for rapid response.
• Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
• Reached out to insurance carriers to obtain prior authorization for testing and procedures.
• Created and maintained spreadsheets detailing medical procedures and insurance denials and approvals.
• Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
• Input all patient data regarding claims and prior authorizations into system accurately.
• Developed and maintained productive working relationships with healthcare providers.

• Finalized and processed enrollment applications.
• Met or exceeded enrollment and retention goals consistently.
• Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.

• Answered customer telephone calls promptly to avoid on-hold wait times.

• Answered constant flow of customer calls with minimal wait times.

• Offered advice and assistance to customers, paying attention to special needs or wants.

• Provided primary customer support to internal and external customers.

• Recommended products to customers, thoroughly explaining details.

• Responded to customer requests for products, services and company information.

• Maintained strong knowledge of basic medical terminology to better understand services and procedures.

• Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
• Addressed customer complaints and mitigated dissatisfaction by employing timely and on-point solutions.
• Took payment information and other pertinent information such as addresses and phone numbers to place orders.
• Answered customer telephone calls promptly to avoid on-hold wait times.
• Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.
• Participated in team meetings and training sessions to stay informed about product updates and changes.
• Achieved high satisfaction rating through proactive one-call resolutions of customer issues.
• Provided primary customer support to internal and external customers.
• Developed customer service improvement initiatives to decrease customer wait times.

• Applied HIPAA privacy and security regulations while handling patient information.
• Interviewed patients upon entrance to hospital, gathered appropriate information and entered data into electronic system.
• Optimized provider time and treatment room utilization with appropriate appointment scheduling.
• Applied knowledge of payer requirements and utilized on-line eligibility systems to verify patient coverage and policy limitations.
• Registered patients by completing face-to-face interviews to obtain demographic, insurance and medical information.
• Communicated financial obligations to patients and collected fees at time of service.
• Updated reference materials with Medicare, Medicaid and third-party payer requirements, guidelines, policies and list of accepted insurance plans.
• Explained various admission forms and policies, acquiring signatures for consent.

• Investigated rejected and denied claims, correcting applicable coding.
• Received, organized and maintained all coding and reimbursement periodicals and updates.
• Read through patient health data, histories, physician diagnoses and treatments to gain understanding for coding purposes.
• Interpreted medical reports to apply appropriate ICD-9, CPT-4 and HCPCS codes.
• Maintained strict confidentiality with adherence to HIPAA guidelines and regulations.
• Maintained high accuracy rate on daily production of completed reviews.
• Maintained current working knowledge of CPT and ICD-10 coding principles, government regulation, protocols and third-party billing requirements.
• Communicated with insurance companies to research and resolved coding discrepancies.

• Submitted claims to insurance companies and researched and resolved denials and explanations of benefit rejections.
• Performed accurate and fully compliant monthly closing processes, accruals and journal entries.
• Provided prompt and accurate services through knowledge of government regulations, health benefits and healthcare terminology.
• Contacted insurance providers to verify insurance information and obtain billing authorization.
• Monitored past due accounts and pursued collections on outstanding invoices.
• Answered customer invoice questions and resolved issues discovered during invoicing and collection process.
• Prepared and posted weekly payments to vendors and suppliers.

• Supervised day to day activities of the Referral Services department including: interviewing, hiring, and training employees; planning, assigning, and directing work; evaluating performance; rewarding and disciplining employees; addressing complaints and resolving problems
• Assisted providers, members and/or internal customers with cases pertaining to referral questions, issues and prior authorizations
• Reconciled pended claim issues in a timely manner per health plan/department procedure
• Reviewed and processed denial letters, maintained logs, and coordinated decisions to external or internal personnel per plan procedures
• Received and reviewed incoming phone and case management log reports and determined course of action
• Worked with analysts and programmers in adapting and testing programs and procedures to adhere to our standard operating procedure
• Created step by step work process
• Familiarized with Policy and procedures
• Oversaw day to day operations of the team, distributed the workload evenly amongst staff and maintained motivation and performance levels
• Answered members and providers questions and gave information regarding the business procedures and policies in an exact and customer-friendly
• Prepared monthly audits, quarterly, and annual reports for therapy log to ensure compliance with the process and turn-around timeframe (TAT) for all markets notification
• Processed authorizations using CPT codes and ICD9 and ICD10
• Reviewed Medicaid and Medicare of members
• Assisted different Health plans with Behavioral process/request
• Assisted with psych evaluation request

• Supervised day to day activities of the Referral Services department including: interviewing, hiring, and training employees; planning, assigning, and directing work; evaluating performance; rewarding and disciplining employees; addressing complaints and resolving problems
• Assisted providers, members and/or internal customers with cases pertaining to referral questions, issues and prior authorizations
• Reconciled pended claim issues in a timely manner per health plan/department procedure
• Reviewed and processed denial letters, maintain logs, and coordinated decisions to external or internal personnel per plan procedures
• Received and reviewed incoming phone and case management log reports and determined course of action
• Worked with analysts and programmers in adapting and testing programs and procedures to adhere to our standard operating procedure
• Created step by step work process
• Familiarized with Policy and procedures
• Oversaw day to day operations of the team, distributed the workload evenly amongst staff and maintain motivation and performance levels
• Answered members and providers questions and gave information regarding the business procedures and policies in an exact and customer-friendly
• Prepared monthly audits, quarterly, and annual reports for therapy log to ensure compliance with the process and turn-around timeframe (TAT) for all markets notification
• Processed authorizations using CPT codes and ICD9 and ICD10
• Reviewed Medicaid and Medicare of members
• Assisted different Health plans with STRS process
• Reviewed Audits

• Attended, participated and set up weekly and monthly team meetings
• Oversaw the Medical Management denial process including letter printing, tracking and disposition of letters within contractual guidelines to ensure compliance
• Monitored all CMS Avaya Claims call queues to ensure service level expectations are met as contractually outlined
• Served as the department liaison and trainer for all denial and/or appeals issues
• Acted as a resource for other staff
• Proved ability to answer members and providers questions and give information regarding the business procedures and policies in an exact and customer-friendly
• Implemented new initiatives and making sure all staff understand them
• Prepared monthly audits, quarterly, and annual reports for denials and/or appeal log to ensure compliance with the denial process and turn-around timeframe (TAT) for all denial and/or appeals notification
• Reviewed and processed denial letters, maintain logs, and coordinated decisions to external or internal personnel per plan procedures
• Trained new team members by relaying information on company procedures and safety requirements.
• Monitored team performance and provided constructive feedback to increase productivity and maintain quality standards.
• Evaluated employee skills and knowledge regularly, training, and mentoring individuals with lagging skills.

• Assisted in monitoring utilization of medical services to assure cost effective use of medical resources through processing prior authorizations
• Initiated authorization requests for outpatient and inpatient services in accordance with the prior authorization list
• Routed to appropriate staff when needed
• Verified eligibility and benefits
• Answered phone queues and process faxes within established standards
• Entered authorizations into the system
• Trained others on authorizations and/or faxed work processes