Insurance billing specialist

Magellan Health, Inc./TennCare | Nashville, TNProgram Coordinator- Administrative Assistant06/2013 - 12/2019 • Successfully coordinate and organize meetings for clients for quarterly PAC (Pharmacy Advisory Committee) meetings and DUR (Drug Utilization Review) meetings.• Manage account team's project needs.• Achieved the development and implementation of short and long term procedures for the TennCare Appeals Program.• Take in, compile claim information and distribute appeals, allowing the PharmD to review appeals with all information in one place.• Assist the pharmacist in completing appeals, successfully and timely.• Review and complete reimbursement appeals.• Review and complete Lock in appeals for the client.• Remain knowledgeable of the strict TennCare updating guidelines.• Resolved patient eligibility errors within the PBM system.• Review and complete "claim too old" reject requests called in from pharmacies• Liaison for the state's building organizer to distribute important information to account team.• Managed office supplies and needs for account team.• Trainee to new employees on all systems and procedures.• PBM point person for the state's Lock In program; entry, letters, historical records upkeep and appeals.• Managed the set-up of templates for all lock in letters including the mail merges for those letters.• Successfully trained 2 states and the Internal Magellan RetroDUR Support team on how to produce mass letters using mail merge.• Created letter set up and merge files for client mailings to providers and patients.• Aided in the setup, completion and the continued upkeep of the TennCare lock in "Watch list" process and procedures.• Improved and simplified the contractually required Lock in reports with all information in one location.

•Coordinate and organize meetings for clients for quarterly PAC (Pharmacy Advisory Committee) meetings and DUR (Drug Utilization Review) meetings.• Volunteered to complete tasks for staff on remote team in Nashville Catamaran office.• Managed the entry of data for various pharmacy programs i.e.: Verification of Benefits and retro DUR responses.• Resolved problems with outside pharmacy providers with submission of electronic claims.• Managed and improved the process for monthly lock in letters for printing and mailing with vendor.• Contact and distributor of weekly Payment reports and DCS letters to the state.• Managed the daily take in, distribution and compiling of results for reconsideration appeal cases and outcomes.

• Coordinate and organize meetings for clients for quarterly PAC (Pharmacy Advisory Committee) meetings and DUR (Drug Utilization Review) meetings.• Perform task for staff on remote team in Nashville First Health office• Data entry of various pharmacy programs ie: Verification of Benefits and retro DUR responses.• Assist outside pharmacy providers with submission of electronic claims• Enter and retrieve data from online Point of Sale claim system.• Review, along with a pharmacist, patient profiles to determine who meets criteria to be locked into a specific pharmacy location.• Create systematic program to generate and track members for the fraud and abuse programs.

• Patient/customer service• Take call in prescriptions from doctors and nurses• Enter prescription information into database for adjudication • Inventory specialist• Manage Patient check out procedures• Train all new technicians and pharmacist for store• Keep daily, weekly and monthly paperwork up to date and accurate • Coordinate and work flu shot clinics within store. Process claims and paperwork for clinics.