Terri Jones, R.N.
Perrysburg,OH
Summary
Experienced Nurse Insurance Specialist successful at managing high caseloads in fast-paced environments and with a positive attitude. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 25 years of experience and willingness to take on any challenge. Seasoned collaborator experienced in meeting needs, improving processes and exceeding requirements in team environments. Diligent worker with strong communication and task prioritization skills.
Overview
39
39
years of professional experience
Work History
Provider Appeal Analyst
Paramount Healthcare
02.2010 - 02.2023
- Clarified provider issues and determined root cause of problems in order to resolve issues.
- Worked provider appeals in date order.
- Identified trends or patterns in provider's surgical and other appeal issues.
- Upheld security and confidentiality of documentation and provider/member data.
- Maintained up-to-date knowledge of product and service changes.
- Wrote required policies and procedures that reflected all regulatory compliance requirements for Medicaid and Medicare provider appeals.
- Provided customer support to internal and external customers.
- Participated in team meetings and training sessions to stay informed about provider updates and changes.
- Responded proactively and positively to rapid change.
- Worked on two different systems for Medicaid and Medicare cases.
- Worked with partner and provided updates and training as needed.
- Sought ways to improve processes and services provided.
- Implemented ICD10 and CPT-4 code solutions to resolve provider issues.
- Maintained strong knowledge of medical terminology to better understand services and procedures.
- Checked documentation for accuracy and validity on updated systems.
Pharmacy Analyst
Paramount Healthcare
01.2007 - 02.2010
- Resolved provider pharmacy requests against pharmacy processes, and if not able to resolve, sent case to medical director for decision.
- Communicated with providers, ensuring that medical information was kept private.
- Entered and updated in provider databases requests for and resolution of medication requests.
- Worked effectively in fast-paced environments.
- Developed and updated policies and procedures, maintaining compliance with guidelines relating to HIPAA, benefits administration and general liability.
- Managed over 30 phone calls per day.
Member Service Appeal Coordinator
Paramount Healthcare
09.1997 - 01.2007
- Discussed appeal issues with members and clarified their appeal issue using strong communication skills.
- Investigated and resolved member inquiries, complaints and appeals quickly.
- Updated cases and continued to communicate with members about their appeal.
- Actively listened to members, handled concerns quickly and escalated major issues to medical director.
- Contacted providers to obtain additional information.
- Worked multiple organizational data collection systems to identify workflow, communication, and appeal issues.
- Trained new personnel regarding member appeal process.
- Skilled at working independently in team environment.
- Self-motivated, with strong sense of personal responsibility.
- Proven ability to learn quickly and adapt to new situations.
- Worked effectively in fast-paced environment.
- Managed time efficiently in order to complete all tasks within deadlines.
- Demonstrated respect, friendliness and willingness to help wherever needed.
- Excellent communication skills, both verbal and written.
- Passionate about learning and committed to continual improvement.
- Provided primary member support to internal and external customers.
- Developed customer service policies and procedures to meet Medicaid, Medicare and Commercial standards.
- Exhibited high energy and professionalism when dealing with members and staff.
- Maintained up-to-date knowledge of products and regulatory requirements for Medicaid, Medicare and Commercial policies.
- Developed and updated databases to show member service appeal resolution data.
- Managed over 20 customer calls per day.
- Delivered exceptional customer service to every customer by leveraging extensive knowledge of products and services and creating welcoming, positive experiences
Nurse Consultant and Trainer
Aetna
05.1996 - 07.1997
- Educated nurses on proper use of products and systems.
- Performed continuous evaluations of content and plans to enhance delivery and improve effectiveness.
- Did audits on 30+ nurses every month.
- Worked in Toledo but reported to Columbus office.
Nurse Trainer and Auditor
Aetna
09.1990 - 05.1996
- Educated nurses on proper use of products and systems.
- Performed continuous evaluations of content and plans to enhance delivery and improve effectiveness.
- Responsible for training all of Ohio's new nurses.
- Trained 55 nurses in managed care environment.
- Utilized electronic medical record systems to store, retrieve and process patient data
- Communicated effectively with staff, patients, and insurance companies by email and telephone
- Maintained accuracy, completeness, and security for medical records and health information
- Scanned and uploaded medical records into electronic medical records system
Staff Nurse
Riverside Methodist Hospital
04.1987 - 03.1990
- Worked in Neuro ICU Stepdown and was often working in Neuro ICU.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
Staff Nurse
Central DuPage Hospital
06.1984 - 01.1987
- Worked in Medical Surgical floor. Was asked to work in other floors, such as, orthopedics.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
Staff Nurse
Cook County Hospital
11.1983 - 06.1984
- Worked in mens urology floor. Asked to work in other areas, such as, trauma, neurology.
- Performed various nursing interventions such as wound dressing, vital sign monitoring, and specimen collection.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
- Assessed physical, psychological, physiologic, and cognitive status of patients.
- Monitored patients' conditions and reported changes in physical presentation, appearance, and behavior to discuss treatment with physicians.
Education
Associate of Science - Nursing
College of DuPage
Glen Ellyn, ILSkills
- Microsoft Word
- Microsoft Access
- Microsoft Outlook
- Google Chrome
- Power Point
- Excell Spreadsheet
- Office Machines
- HMS System
- Amisys System
- Provider Relations
- Appeals processing
Accomplishments
Licensed in Indiana as well as Ohio. At least 24 CEU's per year. Participated in Administrative Law Judge hearings in Federal Court for Medicare as well as State Hearings for the Medicaid population. Participated in NCQA multiple times. Worked with Ohio Department of Insurance for various issues.
My hobby is silversmithing. I have a business on Etsy selling vintage Native American jewelry
I learned silversmithing many years ago after doing beading work. I studied at the Toledo Museum of Art as well as learning on my own. I have participated in multiple craft shows in the State of Ohio. I have also given lessons at the Toledo Botanical Gardens after joining the Rock Group. I currently have a workshop in my basement and plan to add some to my Etsy store.
I also have a store on Etsy selling vintage turquoise and Native American jewelry. I love the hunt for vintage items and placing the jewelry in my store.
Timeline
Provider Appeal Analyst
Paramount Healthcare
02.2010 - 02.2023
Pharmacy Analyst
Paramount Healthcare
01.2007 - 02.2010
Member Service Appeal Coordinator
Paramount Healthcare
09.1997 - 01.2007
Nurse Consultant and Trainer
Aetna
05.1996 - 07.1997
Nurse Trainer and Auditor
Aetna
09.1990 - 05.1996
Staff Nurse
Riverside Methodist Hospital
04.1987 - 03.1990
Staff Nurse
Central DuPage Hospital
06.1984 - 01.1987
Staff Nurse
Cook County Hospital
11.1983 - 06.1984
Associate of Science - Nursing
College of DuPage
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