Sandra E. Email & Phone Number

Charlotte, North Carolina, United States

• Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. • Triages resulting rework to appropriate staff. • Provide excellent customer services for high volume inbound provider calls for the Claims Inquiry/Claims Research team.• Extensive claims research on multiple platforms to assist providers with payment questions.• Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc. • Uses customer service threshold framework to make financial decisions to resolve member issues. Explains members’ rights and responsibilities in accordance with contract.• Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievances and appeals (member/provider) via target system .• Assists in compiling claim data for customer audits. Determines medical necessity, and applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.

Charlotte, North Carolina, United States

-Applied knowledge of medical terminology, medical billing guidelines, and fee schedules, Including CPT/ICD/HCPS coding and Knowledge of UB-O4 and CMS- 1500 form types.-Researched CPT and ICD-10 coding discrepancies for compliance and reimbursement accuracy for over 150 bills per day.-Located errors and promptly refiled rejected claims.-Identified appropriateness of charges and associated coding on bills assigned daily.-Calculated and applied savings associated with reviews.-Comply with customer special handling and jurisdictional guidelines.-Utilize review system to appropriately document work and final conclusions.

Charlotte, North Carolina, United States

Medical insurance verification and patient access

Charlotte, North Carolina, United States

-Obtained benefits and prior approval from patient's insurance carrier for all surgical cases.-Documented benefits and prior approval including notes in PM Alert system.-Acted as effective liaison between patient, surgeon, primary care physician, insurance company, hospital, and patient surgery coordinator in disseminating insurance benefits.-Assessed situations and forwarded to physicians’ team or other staff as appropriate.-Maintained accurate account of all surgical insurance verifications electronically.-Working knowledge of patient management systems including insurance, information, and verification modules.-Knowledge of Retina processes within precert dept to be able to obtain the most accurate authorization needed for the patient. ( buy and bill, specialty pharmacy, samples vs stock, Step Therapy, benefits investigations, and financial assistance).-Applied necessary communication in the PM and EHR alerts to the clinical teams.-Maintained and obtained necessary VA authorizations for all HEC services provided to veteran patients.-Obtained prior authorizations for necessarily ordered radiology (MRI's, and CTScans) for HEC providers.-Ensured patient confidentiality and adheres to HIPAA requirements using all methods necessary including non-disclosure to unauthorized personnel, limiting record access and shredding discarded patient information.