Bertha Wright Email & Phone Number

Investigation of appeals from participating and non participating providers.Research of claims payment and authorization with updating of those systems for payment.Decision making of appeals for possible overturns and upholding of denials.Involved in training process for the employees within the Appeals and Grievance Department.Preparing appeal cases to be sent to external reviewer for 2nd level appeals.Preparing appeal cases to be sent to Maximus for review.Reviewing behavioral health and external law office cases.Claims projects assigned by manager.

Authorizing outpatient referrals in Medical Management System and Claims System, increasing claims payment which resulted in better customer satisfaction.Assisting Medical Management staff with referral process.Providing assistance to the Claims department and Member Services department with issues from members.Involved in training process for all employees of the Medical Management Department.

Responsible for adjudication of claims for the Appeals/Retrospective Review Departments.Gathering and the research of information to adjust/reprocess claims for appeals.Assisting other departments within the company with the appeals process.

Responsible for Inpatient Admission pre-certification.Providing assistance and guidance to the other Managed Care Representatives.Assisting providers, members and facilities in obtaining authorizations/referrals.Providing training to new employees, improving there knowledge of the work system.

Responsible for front office reception.Scheduling all appointments and pulling medical records for those appointments.Answering phones and taking messages.Assisting patients with lab results and prescriptions.Occasional back office duties, including escorting patients to rooms and documenting problems.

Responsible for all front desk duties.Scheduling of patients for the OB/GYN department.Answering calls, taking messages and phoning in prescriptions.Pulling medical records for appointments and messages.Occasional back office duties, including escorting patients back to rooms.; Windows, MS office, EZ Cap, Logician, QNXT, Access, Sharepoint