Vanessa Moore
Columbia,MD
Summary
Highly skilled healthcare professional with over 10 years of experience in the revenue cycle, case management, and prior authorization sectors. Proven track record in improving operational efficiency, enhancing patient care coordination, and optimizing insurance claim processes. Seeking a remote role in healthcare insurance management with a focus on driving quality outcomes and increasing reimbursement rates.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Reimbursement Coordinator
Cardinal Health
Lewisville, Texas
11.2024 - Current
- Remote
- Facilitated communication between patients, providers, and payers to resolve claim discrepancies, and expedite payment processing.
- Collaborated closely with medical coders to ensure the accurate representation of services provided, resulting in optimized reimbursement potential.
- Implemented and maintained electronic claims submission systems, reducing paper waste, and improving processing efficiency.
- Increased staff productivity by providing ongoing training and support on relevant software systems and tools.
- Established strong relationships with payer representatives, fostering open communication channels that facilitated problem resolution and expedited claim approvals.
- Ensured timely payments for clients through diligent monitoring and follow-up on outstanding claims.
- Contributed to successful appeals efforts by compiling necessary documentation and presenting persuasive arguments on behalf of patients, or providers, seeking coverage reconsideration from insurers.
- Managed approximately 45 outbound calls, emails, and faxes per day to customers and healthcare providers.
Case Management Coordinator
Trillium Health Resources
Greenville, NC
12.2023 - 11.2024
- Remote
- Collaborate with agents, professionals, and clinicians to enhance service and support initiatives for members, and stakeholders.
- Lead projects to refine information dissemination to members, recipients, families, providers, and community stakeholders, ensuring accuracy and relevance.
- Coordinate complaint and grievance resolution processes to improve member satisfaction, and foster increased engagement and access to care.
- Managed approximately 80 incoming calls, emails, and faxes per day from customers and healthcare providers.
Medical Claims Specialist
AmeriHealth Caritas Family of Companies
Philadelphia, Pennsylvania
11.2022 - 11.2023
- Remote
- Resolved customer inquiries and complaints efficiently, ensuring a high level of satisfaction while adhering to service level agreements, and productivity standards.
- Educated customers on billing, payment, and support processes, enhancing their understanding and experience with the company's policies and procedures.
- Processed medical claims accurately and in compliance with established criteria, utilizing administrative guidelines, and knowledge of medical terminology, claims principles, and HIPAA regulations.
- Conducted quality assurance audits, maintained up-to-date expertise in CMS guidelines, and handled Provider MAID verification and enrollment.
- Managed approximately 80 incoming calls, emails, and faxes per day from healthcare providers.
Reimbursement Coordinator (DRG)
AmeriHealth Caritas Family of Companies
Philadelphia, PA
08.2017 - 10.2022
- Assessed medical guidelines and insurance benefits to authorize necessary healthcare services, handling up to 60 inbound and outbound calls daily, and coordinated with the Medical Director and specialized nurses to resolve criteria failures and secure approvals.
- Acted as HEDIS Coordinator for obstetric care, overseeing the entire process from admission to discharge for mothers and neonates, and conducted 40 to 60 provider outreach calls daily to ensure quality and continuity of care.
Prior Authorization Specialist
AmeriHealth Caritas Family of Companies
Philadelphia, PA
04.2013 - 08.2017
- Remote
- Assessed medical guidelines and insurance benefits to validate the necessity of healthcare services, and executed prior authorization reviews.
- Conducted admission evaluations and coordinated discharge planning, aligning with DRG contracts and managed care requirements.
- Managed comprehensive utilization review documentation, and escalated cases to appropriate healthcare professionals for resolution.
- Functioned as a knowledgeable resource on prior authorizations, claims, and admissions, and coordinated HEDIS efforts for obstetric care, ensuring compliance from admission to discharge.
- Managed approximately 80 incoming calls, emails, and faxes per day from healthcare providers.
Medical Assistant
Wayne Medical Arts
Philadelphia, PA
10.2011 - 04.2013
- Maintained a clean and organized clinical environment by sanitizing exam rooms and medical equipment, ensuring readiness for patient examinations.
- Documented comprehensive patient information, including medical history, vital signs, and medication details, while also performing routine administrative tasks, such as data entry and appointment scheduling.
- Assisted healthcare professionals with diagnostic procedures, managed inventory supplies, and facilitated communication with pharmacies for prescription management.
Certified Nursing Assistant
Philadelphia Nursing Home
Philadelphia, PA
08.2009 - 11.2011
- Assisted with daily living activities, including personal hygiene and feeding, ensuring adherence to individual nutritional plans, and promoting patient safety.
- Provided targeted care for a diverse patient population, including those with chronic conditions such as respiratory failure, diabetes, and Parkinson's disease, by conducting routine evaluations and supporting therapy exercises.
- Collaborated with healthcare professionals to monitor and manage patient health through regular vital sign checks, condition assessments, and timely responses to emergent needs.
Education
High School Diploma -
Parkway Northwest HS
Philadelphia, PABachelor of Science - Healthcare Administration
Western Governors University
Skills
- Revenue Cycle Management
- Medical Billing and Coding (CPT, ICD-10, HCPCS)
- Prior authorization and utilization review
- Healthcare Operations Management
- Claims processing and appeals
- Case Management (remote)
- Healthcare Compliance and Regulatory Knowledge
- Data Analysis and Reporting
- Strong knowledge of insurance plans (commercial, Medicare, Medicaid)
- EMR/EHR systems (Epic, Cerner, Meditech)
- Billing Software (NextGen, Availity, Trizetto)
- Microsoft Office Suite (Excel, Word, PowerPoint)
- Project Management Tools (Asana, Trello)
Certification
- Licensed Health Insurance Agent/Broker
- Federally Facilitated Marketplace (FFM) Certification
Timeline
Reimbursement Coordinator
Cardinal Health
11.2024 - Current
Case Management Coordinator
Trillium Health Resources
12.2023 - 11.2024
Medical Claims Specialist
AmeriHealth Caritas Family of Companies
11.2022 - 11.2023
Reimbursement Coordinator (DRG)
AmeriHealth Caritas Family of Companies
08.2017 - 10.2022
Prior Authorization Specialist
AmeriHealth Caritas Family of Companies
04.2013 - 08.2017
Medical Assistant
Wayne Medical Arts
10.2011 - 04.2013
Certified Nursing Assistant
Philadelphia Nursing Home
08.2009 - 11.2011
Bachelor of Science - Healthcare Administration
Western Governors University
High School Diploma -
Parkway Northwest HS
Similar Profiles
Corinne RestaniCorinne Restani
SR. Accounts Receivable Specialist at Cardinal HealthSR. Accounts Receivable Specialist at Cardinal Health
Ramon DuqueRamon Duque
Senior Pharmacy Technician at Cardinal HealthSenior Pharmacy Technician at Cardinal Health
John NguyenJohn Nguyen
Supv, Warehouse Operations at Cardinal HealthSupv, Warehouse Operations at Cardinal Health
JERRY P. RUSSELLJERRY P. RUSSELL
Extended Care Product Specialist – Post Acute at Cardinal HealthExtended Care Product Specialist – Post Acute at Cardinal Health
Katia RossettiKatia Rossetti
Research Assistant II at Henry M Jackson FoundationResearch Assistant II at Henry M Jackson Foundation