Zainab Shamsideen
Saint Petersburg,FL
Overview
9
9
years of professional experience
Work History
Grievance and Appeals Representative
Humana
03.2023 - Current
- Processed and finalized appeals and grievances within agreed-upon turnaround time.
- Remained knowledgeable regarding company policies and procedures and current developments within operational departments.
- Assisted management in identifying areas for improvement, contributing to overall department efficiency gains.
- Enhanced the accuracy of appeal decisions through thorough research and fact checking.
- Prepared detailed reports summarizing appeal outcomes for management review, enabling data-driven decision-making processes within the department.
- Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques
Long Term Care Coordinator
MetLife
06.2019 - 02.2023
- Conducts in depth detailed information-gathering phone calls that obtain medical condition details and other information
- Compiles file documentation requiring extensive policy and factual detail
- Provides timely, balanced and accurate claims reviews, documentation and recommended decisions in a time sensitive and fast paced environment
- Identifies information and resources needed to make benefit eligibility determinations
- Communicates decisions to policyholders and or their representatives in both verbal and written form
- Clarifies and reconciles inconsistencies
- Manages assigned caseload with limited supervision
- Follows organizational guidelines to assure compliance with HIPAA and policyholders confidentiality standards.
Prior Authorization Specialist
Blackstone Medical Services
05.2018 - 06.2019
- Contacted insurance companies to obtain the necessary prior authorizations needed for upcoming appointments
- Identified reasons behind denied claims and worked closely with insurance carriers to resolve denials
- Used Abbadox to input claim, prior authorization and other important medical data into the computer system
- Kept operations running smoothly and solved diverse problems by coordinating with customers, management and internal departments
- Extensive knowledge in using Evicore, Availity, SMS/Carecentrix, and AIM portals
- Followed all Medicare, Medicaid, HIPAA, and private insurance regulations and requirements
- Assisted in training new hires.
Prior Authorization Specialist
Aetna, a CVS Health Company
07.2016 - 04.2018
- Properly documented all information for all requests and ensured a timely decision for the member
- Authorized approval of prior authorization requests from doctors received by telephone and also via fax
- Exceptional knowledge in DPAS and COS systems
- Assisted in training new hires
- Worked with all forms of Medicare
- Researched denied claims and contacted insurance companies to resolve these issues.
Licensed Pharmacy Technician/ Prior Authorization Specialist
Johns Hopkins All Children's Hospital
06.2015 - 07.2016
- Prepacked bulk medications filled bottles with prescribed medications
- Answered telephones, responding to questions or requests
- Delivered medications or pharmaceutical supplies to patients, or nursing stations
- Assisted in prior authorizations, follow up calls, and coordinate between insurances and specialty pharmacies for home deliveries
- Contacted insurances for medication override
- Prepared and processed medical insurance claim forms and records
- Maintained customer and patient confidentiality
- Communicated with all customers and staff in a pleasant and professional manner
- Appropriately resolved customer issues, complaints and questions
- Modified treatment plans according to changes in client status
- Assisted in case management activities and processes.
Education
2-15 License Health & Life -
Florida
01.2018
GED -
Dixie Hollins Adult Education Center
Kenneth City, FL01.2012
Skills
- Pharmacy Technician Experience
- Case Management
- Medical Terminology
- HIPAA
- Detail Oriented
- Communication skills
- Problem-solving abilities
- Exceptional Patient Care and Interaction
- Outstanding Customer Service
- Computer: Word, Excel, PowerPoint, Internet and Email
- Hospital, Retail Pharmacy, and Call Center Professional
- Insurance Verification
- Bilingual : English and Arabic
- Medical Billing
- ICD-10 Coding
- Policy Interpretation
Languages
Arabic
Native or Bilingual
English
Native or Bilingual
Timeline
Grievance and Appeals Representative
Humana
03.2023 - Current
Long Term Care Coordinator
MetLife
06.2019 - 02.2023
Prior Authorization Specialist
Blackstone Medical Services
05.2018 - 06.2019
Prior Authorization Specialist
Aetna, a CVS Health Company
07.2016 - 04.2018
Licensed Pharmacy Technician/ Prior Authorization Specialist
Johns Hopkins All Children's Hospital
06.2015 - 07.2016
2-15 License Health & Life -
Florida
GED -
Dixie Hollins Adult Education Center
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