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Quality Coordinator - 20 Years of Experience - Near 11590


Quality Coordinator


Jericho, NY

Education Level:

Some College Units Completed

Will Relocate:



Professional with 15+ years of experience in the healthcare industry. Seeking a challenging opportunity with growth potential within an expanding organization where I can utilize my years of reimbursement, collection and Appeals/Grievances experience with outstanding interpersonal, communication and organizational skills. NORTHWELL HEALTH, CARECONNECT A&G Investigator - Greenvale, NY - January 2017 - present * Facilitates member and provider grievance and appeals in compliance with federal and state regulatory standards related to bills, appeals, services and access to care related issues. * Ensures assigned grievance issues are resolved within appropriate time restraints. * Completes and thoroughly documents grievances. Maintains grievance information and supporting documentation in accordance with regulatory requirements. * Independently conducts thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities * Researches and resolves open/pending issues in a timely manner to ensure member satisfaction. * Prepares written responses to all member and provider correspondence that appropriately address the complainant's issues and are structural accurate. * Ensures members have access to providers and specialty providers identifies available providers and collaborates within CareConnect to resolve complex access issues. * Provides direction to members when filing appeals documents and routes information to A&G Nurse. * Liaison with claims to ensure determinations are completed within timeframes. * Serves as liaison with departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases. * Assist the Manager/Supervisor in developing workflows and process efficiency. * Escalates issues and/or collaborates within CareConnect to resolve complex member issues, as necessary. * Prepares cases for medical and administrative review detailing the findings of their investigation for consideration in the plan's determination. * Make necessary follow-up calls to internal and external entities to ensure that cases are completed on or before the applicable timeframe. * Performs related duties as required. ISLAND CARE PHARMACY PATIENT ADVOCATE - Melville, NY - December 2016 * Serve as a liaison by coordinating between departments to ensure authorizations, grievances and escalated appeals (State Level) are processed in a timely manner. * Communicate with all providers and Sales Team throughout the day for resolutions when necessary review and analyze denials as received. * Follow departmental and organizational guidelines, policies and procedures. * Notify appropriate departments, providers and patients grievance outcome. * Document in computer system all correspondence and documents for each case. * Other duties as assigned. PATIENT CARE SPECIALIST/MLTC COORDINATOR HEALTHCARE PARTNERS, IPA - Garden City, NY - September 2013 to 2016 * Initiate and maintain strong, positive working relationship with physicians and office staff within the MLTC program acting as a liaison between RN's and clients when necessary solving problems in an effective, expedient manner and meet their needs to increase satisfaction * Knowledge of capitation and the effect of managed care on a physician's practice. * Demonstrate marketing and customer relations' skills to interact with physicians, and their office staffs to maintain high satisfaction. * Oversee authorizations are obtained Internal and NYS External Appeals if necessary. Interact effectively with dissatisfied customers/constituents. * Determine eligibility of members, acceptability of evidence submitted, and necessity for additional information or review * Yearly Audits REIMBURSEMENT MANAGER ADVANCED CARE, INC - Farmingdale, NY - January 2013 to June 2013 * Supervised staff of 12 for accuracy of timely verification process, billing, collections, posting of payments authorizations, Internal and External Appeals * Responsible for billing, collections, invoicing, cash receipts, adjustments, balance billing, cash posting, month end and account analysis procedures * Negotiated pricing with vendors and/or private paying patients * Assisted in the implementation of a centralized intake team * Assisted VP with projects as needed COLLECTIONS/REIMBURSEMENT SPECIALIST PROMPTCARE HOME INFUSION - Farmingdale, NY - May 2010 to March 2012 * Negotiated rates with all insurance carriers if necessary: Commercial, Medicare, Medicaid, Managed Medicaid to guarantee assignment of benefits ABN determination for services. * Verified benefits using MEVS and internet then communicate results to patients and sales team enter all referral information into data system code for proper payment heavy workload in high pressured outpatient environment. * Obtained CHHAs for cases needing their services obtain authorization & re - authorizations if necessary. * Contacted patients, referral sources and sales representatives to relay or obtain pertinent information to effect the clearance of all referrals. * Adjudicated claims along with following up on all outstanding balances from insurance companies or patients/ authorizations Internal and External Appeals. * Collections resulting in a 20% increase of revenue. REIMBURSEMENT MANAGER/SPECIALIST TRINITY HOME CARE - College Point, NY - March 2009 to May 2010 * Supervised staff of 10 Intake and Reimbursement departments making sure of accurate and timely filing of claims negotiate pricing with vendors timely referral intake accuracy of authorizations Internal and NYS External Appeals. * Collected all amounts due from either insurance companies or patients, write-off of bad debt. * Negotiated pricing with vendors as needed obtain CHHAs when necessary. * Posted payments analyzed and processed adjustments billing adhered to End of Month procedures working on CPR+ and I-Emphsys REIMBURSEMENT MANAGER CRITICAL CARE SYSTEMS - Plainview, NY - August 2004 to January 2009 (Branch closed) * Reported month-to-date collections, revenue, cost of goods and any payer changes. * Assisted General Manager with Credentialing process when necessary. * Set up facilities, physicians, insurance companies and account executives within the computer. * Verified all commercial insurances, Medicare/Medicaid and patient registration. * Set up of all admission and reimbursement charts, negotiate pricing, case management and self-payment arrangements. * Responsible for billing, invoicing, cash receipts, adjustments, balance billing, cash posting, collections, month end and account analysis procedures. VOLUNTEER The Long Island Council on Alcoholism and Drug Dependence (LICADD) Assist in planning and coordinating activities to solicit and maintain funds for the organization, as well as coordinating activities of staff and vendors to make arrangements for group meetings and events.


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(Confidential) Patient Care Specialist/Mltc Coordinator 6/2016 - Present




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