Appeals Specialist

Posted on: 2008-06-15

C. LINDA JARMON 8636 Temple Road, Philadelphia, PA 19150 215-248-0146 ~ [email protected] SUMMARY OF QUALIFICATIONS > Experienced health care professional with a solid history and background in healthcare and healthcare insurance industry. > Extensive experience processing health care disputes involving both Part A and Part B Medicare services. > Knowledge of Medicare law, regulations, national and local coverage rules, > Adjudication of a diverse assortment of claims > Adjudication of appeals based on coverage as well as medical necessity denials. > Four years experience as a Subrogation Specialist in one of the largest health insurance companies. > Excellent communication skills with the ability to establish good rapport with clients and > Experienced in medical terminology, ICD-9 and CPT interpretation EDUCATION BA, Organizational Management Eastern University, St. Davids, PA Paralegal Studies following ABA Guidelines, Diploma Program Berean Institute, Philadelphia, PA Pharmacy Technician, Certificate Condensed Curriculum Inc., NJ Radiology Technician, Diploma Philadelphia General Hospital School of Radiology, Philadelphia, PA PROFESSIONAL EXPERIENCE FMLA time off from corporate work to take care of ill parent, who is now deceased. 2006 - 2007 MAXIMUS Federal Services, King of Prussia, PA Appeal Officer 2005 - 2006 * Made reconsideration determinations on Medicare appeals * Reviewed cases to determine the facts of each case and assesses issues involved in the case * Reviewed files to determine whether all relevant information has been submitted. * Identified and matched denied item(s) within the case file, the denial rationale presented by the Medicare contractor and arguments of appellants. * Correctly matched denied items and arguments to Medicare policies. * Identified whether the case required review by an independent physician consultant. * Outlined pertinent facts and issues for review by independent physician consultants. * Acquired all necessary information involved in case and rendered a determination based on the information. * Used Internet and hard copy tools to research issues using federal laws and regulations relevant to CMS policies. C. LINDA JARMON Page Two * Performed other special projects not related to specific cases such as general legal and medical research. * Communicated the determination in a clearly written letter and ensured the letter was sent to the appropriate parties. Time off from corporate work to take care of terminally ill parent, who is now 2004 – 2005 deceased but maintained volunteer responsibilities during this entire time INDEPENDENCE BLUE CROSS, Philadelphia, PA 1999 – 2004 Paralegal/Subrogation Specialist * Served as liaison between claims processors, subscribers, providers, legal department and outside counsel. * Conducted detail investigation in discovering information needed for subrogation decisions. * Interpreted factual and legal research of current laws and applicable State Insurance Law regarding subrogation, worker’s compensation, Medicare, ERISA, and motor vehicles accidents for all fifty states. * Investigated, pursued and recovered medical benefits paid in third party liability settlements and judgments for members nationwide. * Recovered over $4M for company as part of a four-member team. * Analyzed and review claims to negotiate favorable settlements for all parties. * Directed efforts and strategies of attorneys and outside vendors through written and telephone correspondence. Medical Policy Specialist * Supported medical staff coordinators through editing and revision of medical policy documents designated for electronic and hard copy publication. * Coordinated main and subcommittee meetings. * Researched medical reference databases and journals for technology assessments. MCNEIL HEALTHCARE, Fort Washington, PA (contract position) 1998 – 1999 Market Research Assistant * Conducted primary and secondary market research with analysis gained through investigation for new product lines (on-site and off-site panels). * Prepared and analyzed reports detailing market research responses through questionnaire format. * Identified target markets for determining business strategies. ABINGTON MEMORIAL HOSPITAL, Abington, PA 1997- 1998 Administrative Assistant (contract position) * Developed and organized data in Excel. * Assisted in the daily operations and management of hospital Volunteer Service department. IMS, Plymouth Meeting, PA 1994 – 1997 Medical Code r(contract position to full-time) * Analyzed and managed pharmaceutical data through evaluation and interpretation of ICD-9 and CPT codes and performed data entry. * Conducted routine quality checks to ensure proper drug identification as related to primary diagnosis. C. LINDA JARMON Page Three COOPER CENTER CITY HOSPITAL (Metropolitan Hospital), Philadelphia, PA 1973 - 1993 C.T./Diagnostic Technician * Provided technical training for newly employed diagnostic and CT technologists. * Managed daily operations of CT Department including prescreening, scheduling, and patient management. COMPUTER SKILLS * Windows XP software, Internet, Excel and Power Point COMMUNITY & PROFESSIONAL AFFILIATIONS Alpha Beta Gamma International Business Honor Society Chapel of The Four Chaplin’s Award Philadelphia Cares Volunteer Services Mary Kay Cosmetics Consultant Notary Signing Agent National Association of Notary Signing Agent Pennsylvania Association of Notary Mt. Carmel Baptist Church, Superintendent, Preschool Department * Developed age-appropriate curriculum for preschool children for past 37 years. * Organized programs for special occasions and religious holidays. * Recruited and developed ten teachers for early childhood instruction. Girl Scouts, Program Chair, Southeastern Pennsylvania * Recruits and supervise volunteers. * Chairperson on subcommittee for Girl Scouts of Eastern Pennsylvania * Girl Scouts of Eastern Pennsylvania Alternate Delegate * Motivate committee with positive results and encourage them to achieve area goals. * Provides leadership including planning, implementing, scheduling, and maintain progress of project activities. * Organized and planned Philly Cares project for Brownie troop * Organized activity for service unit Daisy girl scouts at the Cobbs Creek Environmental Center. * Define problems and determine best resolutions. * Handle evaluation of all programs to maintain consistent success.