Patricia A. Goldman
Fairdale,KY
Summary
Highly dedicated and reliable Insurance Verification Specialist with excellent insurance document organization skills to ensure accurate insurance benefits are made for specific IV and oral therapy medications.
Overview
15
15
years of professional experience
Work History
Benefit Verification Specialist
Onco360
09.2019 - Current
- Research proper billing policies and procedures for all payer types, ensuring claims are processed correctly against industry and government standards and regulations, adhere to company compliance, integrity, patient privacy, and ethical billing practices.
Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards. - Verify Government payer (i.e. Medicare and Medicaid) eligibility and benefits utilizing electronic resources to load primary, secondary, tertiary, etc. insurances to patient profile. This involves contacting Medicare or other relevant government payers to confirm coverage and benefits for specific services.
- Verify Commercial insurance plans eligibility and benefits utilizing electronic resources to load primary, secondary, tertiary, etc. insurances to patient profile. Confirming patient eligibility and benefits with various commercial insurance carriers (i.e. Aetna, Humana, Anthem, Cigna, etc.).
- Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding benefit information and patient copays, deductibles and Out-of-Network responsibilities.
- Determine optimal reimbursement based on medical plan and dispensing location, then document outcome of benefits review in CPR+ system to be used by operations and ensure the order is assigned to the appropriate dispensing pharmacy.
- Facilitate process for requesting medical authorizations, LOAs, and TOAs for applicable commercial, Medicaid, and Medicare, or facility medication claims.
- Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information, doctors’ notes, assessments and lab reports.
- Communicate succinctly and professionally both verbally and through written correspondence with Physician offices, nurses, insurance companies and patients as needed.
- Exhibit a positive, courteous, respectful, and helpful attitude towards patients, team members, payers, and management. Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.
Case Manager III
RX Crossroads/McKesson
08.2014 - 07.2019
- Managing all patient referral from intake through case closure
- Benefit investigations, initiation and follow-up on prior authorizations
- Coordinating and tracking status of payer appeals for drug coverage
- Triaging all prescriptions to the fulfillment pharmacy as applicable
- Investigation of financial assistance availability for patients
- Specialty pharmacy follow-up calls
- Reporting Adverse Events/Product Complaints
- Managing assigned cases and tasks to ensure that performance is within service levels
Disability Case Coordinator
Sedgwick’s CMS
07.2010 - 07.2014
- Monitor STD and SCP cases assigned to DBC, DBC II and DBCM III
- Serve as administrative support for the telephonic case management team
- Send out intro/health coach/tool kit packet on all claims
- Contact treating MD and verify medical release forms
- Send FJPs to BTL daily
- Complete note template within 24hrs
- Confirm ICD-9 code. If discrepancies found contact DBC
- Maintain all medical records
- Maintain Excel spreadsheet of all open claims and lost time
Education
Diploma - Medical Billing
National College of Business and Technology
01.2010
Skills
- Ability to learn new skills quickly and perform well under pressure
- Flexible and able to adapt to changing situations
- Work well with other co-workers and superiors
- Extensive Medicare and commercial insurance experience
- Excellent familiarity with medical and pharmacy environments
- Detailed oriented
- Achievement driven; constant striving to improve or to meet a standard of excellence
Timeline
Benefit Verification Specialist
Onco360
09.2019 - Current
Case Manager III
RX Crossroads/McKesson
08.2014 - 07.2019
Disability Case Coordinator
Sedgwick’s CMS
07.2010 - 07.2014
Diploma - Medical Billing
National College of Business and Technology
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