Karen Parker
Philadelphia
Summary
Experienced professional candidate successful at managing multiple priorities with a positive attitude. Organized, driven and adaptable with excellent planning and problem-solving abilities. Organized and dependable .Offering 24 years of experience and willingness to take on any challenge.
Overview
25
25
years of professional experience
Work History
Provider/ Member Appeals Coordinator
Keystone First Health Plan
03.2013 - Current
- Responsible for ensuring the timely and professional coordination of the provider appeal process
- Adhere to appeals being resolves in accordance with established policy and procedures of Department of Public Welfare and contractual guidelines
- Communicates with providers, practitioners, Departments of Public Welfare and Keystone First/ Amerihealth Caritas Families of companies departments to interpret and enhance understanding of provider appeal process
- Participate and interact with members in member appeal hearings as employee voter to deliberate outcome
- Prepare acknowledgment and response letters to members and providers
- Maintain case records on all complaints, grievances, and appeals
- Identify research and resolve claim disputes received from a variety of sources
- Understanding of claims processing and an ability to research claims issues
- Ability to multitask on multiple appeals simultaneously, prioritizing work and completing within stringent timeframes
- Prepare statistical analysis for required reporting
- Identifying issues, grievances, and appeals to categorize and enter information into the database, creating an individual file folder.
- Developed appeals functions, policies and procedures, and documentation.
- Acted as a departmental resource on appeals matters.
- Created, composed and maintained appeal response templates.
Case Management Technician
Keystone First Health Plan
04.2006 - 03.2013
- Interact with members, providers, case managers and other KMHP associates according to program guidelines
- Maintain in a Microsoft Access database by collecting, entering data and generating reports to measure the program’s outcomes
- Eliminate barriers to health services by coordinating office visit appointments, health education classes and transportation
- Collaborate with member, Complex Case Manager RN/MSW and Account Manager to maintain the member’s health status and quality of life
- Achieve individual monthly quota per performance objective and AOP goals.
Member/Provider Services – Customer Service Analyst
Keystone First Health Plan
10.1999 - 04.2006
- Provided excellent customer service and maintained strong professional relationships with customers
- Professionally and promptly resolved customer questions and problems by thoroughly researching issues, identifying root causes and offering solutions
- Prioritized workload to ensure that deadlines were met, quotas were accomplished, monthly reports were completed.
- Assisted with the training, educating and guiding of new and existing associates to department.
- Under moderate supervision, from supervisor/manager, assisted in conducting root cause analysis and recommended solutions to service related issues to ensure quality service to the customers
- Navigate through pharmacy system to assist member/provider with proper access for prescriptions to be processed
- Meeting company’s department quality goals through ASA and audit systems
- Assisted Enrollment department with enrolling new members, disenrollment and updates in pharmacy system
- Review claims/member bills to ascertain member’s billing status.
Document Control Clerk
Keystone Mercy Health Plan
04.1999 - 10.1999
- Receiving claims and preparing claims for scanning and microfilming
- Manual and system inventory tracking for appropriate record keeping.
- Provided assistance with inbound and outbound document processes, document sorting, logging and work order creation.
Education
Bachelor of Science - Professional And Liberal Studies
St. Joseph University, Community College of Philadelphia
5600 City Ave Philadelphia, Pa05.2022
Certification in Business Administration -
CHI Institute
1999
Diploma - undefined
Overbrook High
1993
Skills
- Professional and Technical Skills
- Microsoft Suite
- Facet/Jiva
- Client Letter
- I-Health
- IMAX/EXP
- Crystal report
- Claims Adjustments
- Excel Spreadsheets
- Appeals Support
Timeline
Provider/ Member Appeals Coordinator
Keystone First Health Plan
03.2013 - Current
Case Management Technician
Keystone First Health Plan
04.2006 - 03.2013
Member/Provider Services – Customer Service Analyst
Keystone First Health Plan
10.1999 - 04.2006
Document Control Clerk
Keystone Mercy Health Plan
04.1999 - 10.1999
Bachelor of Science - Professional And Liberal Studies
St. Joseph University, Community College of Philadelphia
Certification in Business Administration -
CHI Institute
Diploma - undefined
Overbrook High
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