Summary
Overview
Work History
Education
Skills
Timeline
Generic
Tiffani Wilson

Tiffani Wilson

Desoto,TX

Summary

Versatile Managing Director with proven abilities across all levels of organizational management. Talented in developing partnerships, overseeing personnel and developing tactical plans to meet strategic goals. Proven leader with significant background in Revenue Cycle and HUB operations.

Overview

13
13
years of professional experience

Work History

Associate Director of Operations

CareMetx LLC
10.2020 - Current
  • Lead management team responsible for managing group of remote Managers & Reimbursement Specialists within virtual HUB environment
  • Client interfacing
  • Ensuring projects are following company standardized program management process
  • Insightful with channel partners, API, Response Type Codes, Machine learning and AI
  • Develop project plans and track progress against plans for all manufacturing deliverables Maintain productivity standards, reports (JIRA, Tableau, etc.), SLA, KPI, and Reimbursement strategies
  • Understand program contract obligations and be able to communicate to drive program performance
  • Expertise in access and reimbursement issues encompassing coverage, prior authorizations, appeals, exceptions, denials, coding and payer payment guidelines, payer policies, sites of care, understanding of coding guidelines (CPT/J-Code/ICD-10), statutory or commercial pricing structures or mandates, and quality programs related to value based care and clinical care pathways
  • Work cross functionally and collaboratively with partners in Sales, Market Access, Patient Services, Strategic Accounts and more to act as process and Carrier experts.
  • Obtain and maintain knowledge and understanding of payer landscape, including
  • Specialty Pharmacy and utilization management criteria, on national, regional, and local levels
  • Expand long term stakeholder partnerships and build advocacy within HCP offices and highlight actions that support patient access to therapy
  • Offer educational resources to support entire patient journey by optimizing processes for prior authorizations/appeals/specialty pharmacy and addressing access issues
  • Provide leadership for recruiting efforts designed to achieve staffing levels during benefit re-verification planning periods
  • Collaborate with Executive Team of Digital HUB to ensure successful project management activities during benefit re-verification periods
  • Provide reporting and data to support daily and weekly business intelligence around key performance indicators
  • Lead management team with handling escalated challenges associated with training, team performance, and project guidance
  • Assist in development of standard operating procedures regarding HUB operations, program requirements, hiring and training
  • Network with key contacts outside their own area of expertise
  • Exercise’s judgment in selecting methods, techniques, and evaluation criteria for obtaining results.
  • Supported business growth through strategic planning and process development.
  • Formulated analysis assessments to make informed decisions on proposed projects.
  • Assisted in recruiting, hiring and training of team members.

Strategic Initiatives Account Resolution Specialist

Prime Healthcare LLC
02.2019 - 06.2020
  • Vendor Management - Overseeing facilitation of denial and appeal process to identify, develop, billing, researching, and implementing process improvement methodologies.
  • Perform billing activities related to account resolution including but not limited to, revenue recovery, plan updates, insurance verification, payer edit rejections, coding updates, rebills, denials, technical and clinical appeals, contractual review, timely follow ups, cash posting,
    adjustments, and credits.
  • Analyzes CBO monthly reports and identifies interventions as appropriate.
  • Manage 45 hospitals in 14 states utilizing Epic, Meditech (multiple versions), Meditech Magic, Medhost, Relay (Emdeon), Change Healthcare, Availity, Navinet, Payspan, TMHP, etc.
  • Identify problems and counsel staff in a timely and equitable manner.
  • Create Standard Operating Procedure (SOP) and updates
  • Responsible for Managed Care/Commercial/Medicare accounts and contracts.
  • Communicate clearly and efficiently with health plans, departmental leadership, and other departments throughout the Revenue Cycle.
  • Ability to leverage systems, process, resources, and other methods to minimize revenue loss, increase cash flow, and maximize efficiency within the Revenue Cycle
  • Maintain productivity standards and reports
  • Completed in-depth research to investigate claims and resolve problems
  • Monitored aging accounts and reached out to customers to discuss payments

Appeal Management SR. Specialist

NTT Data Corp
10.2018 - 02.2019
  • Validating denial reasons following EOB review
  • Generating appeals based on dispute reasons and contract terms specific to payers, including online reconsiderations
  • Research and determine corrective actions and take appropriate steps to code and route accounts appropriately
  • Solid understanding of reimbursement methodologies to review variances to expected reimbursement (debit and credit balances) based on established guidelines.

Supervisor Team Coordinator

AmerisourceBergen/Lash
08.2015 - 04.2018
  • Responsible for and oversee a team of 20+, various medical and pharmacy reimbursement functions in a HUB environment, including but not limited to accurate and timely coverage determinations, benefit investigations, prior-authorizations, billing analyst, claims, appeals, assisting with ongoing staff training, maintain client satisfaction and demonstrate retention
  • Identify and implement departmental best practices to ensure employees are following best practices, Quality Assurance
  • Act as Subject matter expert by providing day-to-day mentoring to team members on performance metrics (KPI), program processes ensuring team members are performing in-line with program standards
  • Handled FDA approved drugs, NDC, J-Codes, CPT, ICD-10, HCPCS, DX codes
  • Pharmacy, Specialty pharmacy, HCP (claim 1500) & HOP (UB 04)
  • Experience educating HCPs on client specific Patient Service programs (i.e., copay, nurse education, bridge, patient assistance, etc.)
  • Experience with specialty/biologic self-injectable (pharmacy benefit) or physician administered (buy and bill/medical benefit) products
  • Knowledge of Centers of Medicare & Medicaid Services (CMS) policies and processes with expertise in Medicare (Part B – for buy & bill products and Part D for Pharmacy products)
  • Ability to manage ambiguity & problem solve
  • Train new and current team members on program standard operating procedures,
    provides routine updates and addresses team member questions.
  • Understand program contract obligations and be able to communicate to drive program performance. May also identify innovative approaches to enhance the current service.
  • Compiled and provided a wide range of routine reports related to program operations for program management and clients.
  • Identify problems, investigate, recommend, and implement solutions.
  • Identify and recommend innovative solutions to improve and streamline current processes. Monitor adherence to standard operating procedures.

Supervisor Site Coordinator

AmerisourceBergen/Lash
11.2012 - 08.2015
  • Responsible for and oversee a team of 10+, various medical and pharmacy reimbursement functions in a HUB environment, including but not limited to accurate and timely coverage determinations, benefit investigations, prior-authorizations, billing analyst, claims, appeals, prior-authorizations, assisting with ongoing staff training, maintain client satisfaction and demonstrate retention
  • Identify and implement departmental best practices to ensure employees are following best practices, Quality Assurance
  • Handled FDA approved drugs, NDC, J-Codes, CPT, ICD-9, HCPCS, DX codes, Pharmacy, Specialty pharmacy, HCP (claim 1500)
  • Research and resolve any claim denials or underpayment of claims
  • Appeal writing
  • Project Management
  • Aid and reimbursement expertise in new product launch
  • Lead daily activities of assigned team by providing coaching, mentoring, development, guidance, and timely resolution of issues within a team environment
  • Design and implement new product policy and procedures
  • Act as a liaison between and maintain being the single point of contact for healthcare providers and Client Field Reimbursement Managers product manufacture, the client, and the IT department
  • UAT system testing to ensure all IT updates are functioning; Trouble shooting for provided online web service

Reimbursement Counselor

AmerisourceBergen /Lash
10.2011 - 11.2012
  • Provide reimbursement assistance to physician(s) office staff and patients to complete and submit claims
  • Benefit verification of medical and pharmacy insurance coverage in a HUB environment
  • Customer service provided to internal and external customers, healthcare providers, and insurance payers

Benefit Investigation Representative

Theracom/CVS Caremark, Aerotek, Tiffani Wilson
04.2011 - 10.2011
  • Collected medical and pharmacy benefit coverage for multiple sclerosis patients in a
  • HUB environment
  • Made determination to refer patients to various assistance programs accordingly
  • Gathered documentation required to expedite coverage determinations, prior authorizations & referrals

Communication Representative

CVS /Caremark, Aerotek
02.2011 - 04.2011
  • Provided customer care through outbound calls to clients regarding specialty therapy
  • Review medication: verify insurance, side effects, and source appropriate documentation for shipment of specialty medication to accommodate each client
  • Responded to incoming phone requests from patients, provider offices and hospitals with courteous and accurate information

Recruiter

Aegis Communication Group Inc
04.2010 - 12.2010
  • Source candidates through a variety of mediums (web tools, employee referrals, proactive etc.)
  • Develop and build a strong talent pipeline within key skill areas and disciplines
  • Conducted phone interviews to assess applicants relevant knowledge, skills, experience and aptitudes
  • Built strong relationships with internal and external candidates to ensure an excellent hiring experience
  • Evaluated strengths and weaknesses of candidates through effective screening processes

Education

Certification - Scrum

SCRUMstudy
Dallas, TX

Associate of Applied Science -

SANFORD –BROWN COLLEGE (SBC)
Dallas, TX
07.2010

Revenue Cycle Solutions & Therapeutics -

Revenue Cycle Solutions & Therapeutics

Skills

  • Strategic planning and execution
  • Process improvements
  • Performance Analysis
  • Client account management
  • Coaching and mentoring
  • Staff training/development
  • Effective leader
  • Delegation
  • Relationship building
  • Inventory management
  • Employee reviews
  • Product development
  • Recruitment
  • Decision-Making

Timeline

Associate Director of Operations

CareMetx LLC
10.2020 - Current

Strategic Initiatives Account Resolution Specialist

Prime Healthcare LLC
02.2019 - 06.2020

Appeal Management SR. Specialist

NTT Data Corp
10.2018 - 02.2019

Supervisor Team Coordinator

AmerisourceBergen/Lash
08.2015 - 04.2018

Supervisor Site Coordinator

AmerisourceBergen/Lash
11.2012 - 08.2015

Reimbursement Counselor

AmerisourceBergen /Lash
10.2011 - 11.2012

Benefit Investigation Representative

Theracom/CVS Caremark, Aerotek, Tiffani Wilson
04.2011 - 10.2011

Communication Representative

CVS /Caremark, Aerotek
02.2011 - 04.2011

Recruiter

Aegis Communication Group Inc
04.2010 - 12.2010

Certification - Scrum

SCRUMstudy

Associate of Applied Science -

SANFORD –BROWN COLLEGE (SBC)

Revenue Cycle Solutions & Therapeutics -

Revenue Cycle Solutions & Therapeutics

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Tiffani Wilson