Audit, review and correct claims. Research, identify and resolve differences in payment versus expected payment. Submit appeals to insurance companies for denied/underpaid claims with medical documentation and terminology

Assisting Market Medical Directors with Hanover and HCPR Review processes. Data tracking of medical & contractual denials. Forwarding cases & interacting with 5 Regional Medical Directors for their review & determination. Ensuring that cases are appropriately handled. Weekly reports of the disposition of cases sent for review to medical directors. Assisting Supervisor with daily reports.

Perform quality control inspection by monitoring customer service phone calls. Processing Coordination of Benefits & Denials.

Review and audit charts for verification of proper claim submission. Research clinical documentation to appeal for medical necessity. Train and supervise intake and billing department (eligibility, verification, authorization, home health care coordination and medical records submission).

Receive & process requests for prior notification and non-PDL drugs from physician offices. Coordinate evaluation of request by a clinical pharmacist and medical directors.

Compounding of bioidentical hormones (in capsules, creams, triturates, nail solutions and suspension forms), maintaining a product accuracy average of 99%. . Receiving medication orders, , preparing and labeling medications for dispensing.