Tishanna Pinkney
Jersey City,NJ
Summary
Results-driven Managed Care Coordinator with extensive experience in the coordination and implementation of healthcare plans. Proven ability to enhance patient care through effective collaboration with healthcare providers, patients, and insurance companies. Core competencies include exceptional organizational skills and in-depth knowledge of healthcare regulations, leading to marked improvements in managed care efficiency and patient satisfaction. Dedicated to advancing quality care and optimizing processes within the healthcare system.
Overview
3
3
years of professional experience
Work History
Resolution Appeals Analyst (Contract)
Horizon BCBSNJ
Hopewell, NJ
12.2024 - Current
- Reviewed documents for accuracy and completeness prior to processing appeals.
- Interpreted complex rules, regulations, policies and procedures related to appeals.
- Compiled data for appeals cases utilizing Microsoft Office Suite products.
- Maintained accurate records of all activities related to the appeals process.
Managed Care Coordinator II
Metropolitan Jewish Health Systems (Contract)
Manhattan, NY
11.2023 - 06.2024
- Resolved issues related to billing, coding, payments, and denials by working with insurance companies.
- Coordinated with insurance companies to ensure accurate patient coverage information is on file.
- Coordinated with physicians, nurses, social workers, therapists and other health professionals to ensure optimal patient care.
- Followed up with discharged patients after they left the facility to ensure they were receiving adequate post-care support.
- Performed administrative duties such as filing paperwork, answering phones, and scheduling appointments.
- Compiled data for appeals cases utilizing Microsoft Office Suite products.
Managed Care Coordinator
Jersey City Medical Center
Jersey City, NJ
02.2023 - 11.2023
- Ensure all clinical operations comply with Medicare and Medicaid guidelines and other manage care policies
- Manage caseload by providing care coordination to individuals with a primary intellectual/developmental disability diagnosis all of whom receive community-based waiver services
- Enter and approve authorizations for patients being discharge from hospitals to a sub-acute rehabilitation facility or a skilled nursing facility
- Verify CPT codes requiring authorization and network versus non-network providers
- Prepared/Correlate appeals for retroactive denials by third party players for appropriate committee action
- Design, develop, and coordinate service utilization in rehabilitation department of hospital system
- Document confidential patient information, ensuring strict confidentiality, in compliance with HIPAA regulations
Bed Control Coordinator
Rahway Hospital
Rahway, NJ
01.2022 - 02.2023
- Scheduled meetings with hospital administrators to discuss long-term plans for bed capacity.
- Created reports on occupancy rates and other metrics related to bed control operations.
- Coordinated with nursing staff to identify potential solutions for bed shortages or overcrowding.
- Ensured timely notification of any changes in bed availability status due to maintenance or repairs.
- Monitored daily admissions, discharges, and transfers to ensure proper bed utilization.
- Collaborated with medical teams to improve the efficiency of patient flow through the system.
- Maintained accurate records of bed availability and patient census data.
- Negotiated agreements with outside facilities when necessary to provide overflow accommodations.
Education
Doctor of Health Administration - Health Administration
University of Phoenix
Tempe, AZ05-2028
MBA - Healthcare Administration
Saint Peter's University
NJ05.2024
Bachelor of Science - Healthcare Management
Saint Peter's University
NJ05.2023
Associate of Applied Science - Medical Assisting
Hudson County Community College
NJ05.2022
Skills
- Information Management
- Microsoft Office
- EPIC
- Medical Terminology
- Insurance Knowledge
- Excellent Customer Service
- Medical billing and coding knowledge
- CareRadius
- Novologix
References
References available upon request
Timeline
Resolution Appeals Analyst (Contract)
Horizon BCBSNJ
12.2024 - Current
Managed Care Coordinator II
Metropolitan Jewish Health Systems (Contract)
11.2023 - 06.2024
Managed Care Coordinator
Jersey City Medical Center
02.2023 - 11.2023
Bed Control Coordinator
Rahway Hospital
01.2022 - 02.2023
Doctor of Health Administration - Health Administration
University of Phoenix
MBA - Healthcare Administration
Saint Peter's University
Bachelor of Science - Healthcare Management
Saint Peter's University
Associate of Applied Science - Medical Assisting
Hudson County Community College