TATITIA FAILS
Orlando
Summary
Resourceful and detail-driven Appeals and Claims Specialist with over a decade of progressive experience navigating complex insurance systems in high-volume healthcare environments. Expert in analyzing benefit denials, coordinating appeals, and securing successful claim resolutions across PBM, Medicare, and Major Medical lines. Adept at transforming intricate reimbursement processes into clear actions—bridging the gap between patients, payers, and providers. Energized by challenges, driven by outcomes, and known for turning “no” into “approved.”
Overview
13
13
years of professional experience
Work History
Insurance Verification Exceptions III
Walgreens Specialty Pharmacy
01.2017 - 05.2025
- - Spearheaded resolution of complex pharmacy and medical claim denials, including appeal support and documentation for PBM and Major Medical claims.
- - Led benefit investigations to verify coverage, identify prior authorization requirements, and enable claim approval pathways.
- - Supported reimbursement strategy by navigating specialized programs (bridge/quick start, grants, pharma support).
- - Acted as subject-matter expert for appeals support and plan-specific requirements.
- - Delivered claim issue resolution with precision, driving a consistent reduction in patient delays and payer rejections.
Patient Coordinator III
Advance Care Scripts
01.2016 - 01.2017
- - Maintained end-to-end patient care continuity through preemptive scheduling and therapy monitoring.
- - Communicated across teams to ensure regulatory compliance, efficient documentation, and patient satisfaction.
- - Functioned as a central resource for medication access, including plan review and benefit clarification.
Patient Care Advocate
Accredo Specialty Pharmacy
01.2012 - 01.2016
- - Advocated for patients through benefit verification, Medicare education, and claim follow-up.
- - Coordinated with insurers to process appeals, navigate prior authorization workflows, and document outcomes.
- - Assisted in LIS enrollment and Medicare navigation for eligible patients.
Education
Law
Seminole State University
Altamonte Springs, FLDiploma - General Studies
Evans High School
Orlando, FL01.1997
Skills
- Appeals & Reimbursement Strategy
- Claims Analysis
- Denial Management
- Patient Advocacy
- Medical & Pharmacy Benefit Verification
- Prior Authorization Support
- Cross-functional Collaboration
- PBM & Major Medical Expertise
- Documentation & Compliance
- MS Office Suite
- Case Resolution
Timeline
Insurance Verification Exceptions III
Walgreens Specialty Pharmacy
01.2017 - 05.2025
Patient Coordinator III
Advance Care Scripts
01.2016 - 01.2017
Patient Care Advocate
Accredo Specialty Pharmacy
01.2012 - 01.2016
Diploma - General Studies
Evans High School
Law
Seminole State University
Similar Profiles
Shani PoundsShani Pounds
Senior Certified Pharmacy Technician at Walgreens Pharmacy/ Walgreens Specialty PharmacySenior Certified Pharmacy Technician at Walgreens Pharmacy/ Walgreens Specialty Pharmacy
Andrew Romand PharmDAndrew Romand PharmD
Pharmacy Manager Local Specialty at Walgreens Specialty PharmacyPharmacy Manager Local Specialty at Walgreens Specialty Pharmacy
Joanne LigonJoanne Ligon
Regional Account Executive at Walgreens Specialty PharmacyRegional Account Executive at Walgreens Specialty Pharmacy
Samantha AdamsonSamantha Adamson
Registered Nurse at Arnold Palmer Hospital for ChildrenRegistered Nurse at Arnold Palmer Hospital for Children
Erik MillerErik Miller
Merchandise Stocker / Associate at Universal Orlando ResortsMerchandise Stocker / Associate at Universal Orlando Resorts