-responsible for credential it and recredentialing clinical providers with third part insurance payers-work closely with insurance companies to ensure all authorizations are in place and client information is updated to ensure timely reimbursements-submit claims for services-ensure timely and accurate insurance claim processing, query third parties about payment delays, and evaluate and resolve reimbursement issues-resolve outstanding balance from third-party payers, resubmit claims if necessary, and resolve balances in pursuit of prompt payment of claims-review denied claims and follow up with insurance carriers, guarantors, clinic personnel and staff to obtain additional information or clarification to appeal claims and obtain maximum reimbursement-work with Accounts Payable and Receivable and post payments to appropriate accounts-handle client account balances and work with clients to resolve billing or payment issues

Provide remote support to approximately 900 assigned patients taking a prescription medication, by conducting regular telephonic outreach and personalized follow-up.• Update records on multiple systems, customized software and applications with strong attention to detail and accuracy.• Help patients navigate insurance and pharmacy protocols, connect with resources, and respond to individual needs and concerns.

Manage roster of approximately 415 assigned members by conducting telephonic outreach to assess health, environment, nutrition, and psycho-social areas of concerns using variety of interviewing techniques and assessments.• Coached and solved problems in response to assessments with member, identifying and addressing specific goals to support health and behavior change. Included facilitation of communication between multiple internal departments, including Member Enrollment, Member Benefits, Authorizations, Humana Pharmacy, RxMentor, Clinical Access Team, Clinical Intake Team, Medicare Risk Adjustment-Dual Outreach, Social Services, and Behavioral Health. • Optimized health and well-being by providing appropriate interventions, including education, coordination of community based support services, national resources, Integrated Voice Response (IVR) programs, or intervention of Field Care Manager (FCM).

Telephonically assessed Medicare, Humana Commercial, or Humana Group Account members in 7 domains of functioning.• Achieved and / or maintained optimal wellness state by evaluating member needs and requirements.• Enhanced member experience by guiding members and families towards and facilitated interaction with resources appropriate for care and wellbeing of members.• Managed members’ physical, environmental, and psych-social health issues by working in collaboration with multi-disciplinary team, employing variety of strategies, approaches, and techniques.

Administered the following economic assistance programs: Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid, and Medicare Savings Program by monitoring and evaluating program delivery to ensure that needed services were provided to clients within established rules and regulations.• Hired, conducted performance appraisals, established responsibilities, ran team meetings, and supervised each position in a work unit consisting of ten Benefits Specialists and one clerical position.• Played integral part of a team that planned, executed, and finalized a cross-functional project to expedite workflow and simplify processes in the office.• Implemented a process to improve the management of 700 – 800 client case reviews each month.

Provided training, daily advice and guidance, and assistance in case development to Economic Assistance Benefits Specialists in addition to performing same duties as a Benefits Specialist.

Provided assistance and services to approximately 400 low income individuals and their families by interviewing, assessing current life circumstances and financial capabilities, counseling, and identifying available resources.▫ Obtained records, verified collateral information, and determined eligibility for multiple social service programs, including Supplemental Nutrition Program (SNAP), Medicaid, Medicare Savings Program, and Temporary Assistance for Needy Families (TANF).▫ Interpreted rules, regulations, and policies to ensure appropriate benefits and services were provided in an effective and expedient manner to assist in the individual’s basic self-sufficiency.▫ Investigated potential welfare fraud situations and prepared written reports communicating findings and conclusions.