Fanny Julisa Flores

Orlando, FL ***** ab8vh8@r.postjobfree.com 407-***-****

PROFILE

Certified Medical Auditor with over 10 year plus experience in healthcare industry. Expertise in Fraud& Abuse

Inpatient and Outpatient Evaluation Management Services, account receivables, medical record auditing, and

pharmacy claims auditing. Bilingual in Spanish both read and write and translate. Technical expertise in claim

software programs in the insurance healthcare such as pharmacy, subrogation, hospital and physician billing with

root cause analysis findings and defending recoveries. Microsoft applications (MS Word, Excel & Access).

Additional expertise in the following:

• Turbo caps, CPR, Compass+, Pharmacy software billing (Express Scripts pharmacy auditing software)

• Medical Terminology, ICD9 proficient, DST program, IDX, Medsys, (United Healthcare claims software

Facets, Diamond, Cosmos& Unison that are used for Medicaid and Medicare coordination of benefits,

subrogation, fraud & abuse claims reimbursements.)

• Encoder pro knowledge user for Fraud & Abuse auditing.

• Structured query language-process of training and learning.

EXPERTISE / ACCOMPLISHMENTS

Training/ Work Place performance

• Provided audit findings to health plans that served the Community & State markets on exposures or if any

coding aberrancy captured through the audit notified operations to put a stop edit on the CPT or HPCS

for United Medicaid and Medicare claim processing platforms.

• Supervised and managed activities in the Florida Hospital Healthcare System claims department

overseeing 18 employees by keeping claims paid within the 30 day turnaround on clean claims, tracking

PTO approvals and employee performance scorecards.

• Managed the Coordination of Benefits department and its 5 employees and mentored the staff on the

medical records review processes for pre existing conditions which needed flagging in the system and

reviewed system software notes to ensure proper claim coordination and cost savings was expedited for

the FHHS members.

• Participates in conference calls with providers and clients, provider relation involvement and training

related to disputes regarding recovery audit requests related to Med Assurant down coding Evaluation &

Management services for Medicare & Medicaid claims under United healthcare recoveries.

• Communicated with different departments on audit findings and if necessary Standard operating

procedures needed updates informed health plan of the CPT codes which need updating and revised based on

CMS policies for both Express Scripts and United healthcare.

• Mentored CPC coders on the E&M guidelines, as per CMS to defend the recoveries for Ingenix as per

coding guidelines and interacted with other Recovery services on the coding analysis findings.

• Reviewed CMS policies monthly with staff members on updates and changes for both Medicaid and

Medicare to ensure appropriate billing and reimbursement were correctly done for the enteral billing

patient in the 21 skilled nursing facilities for Tandem HealthCare.

Auditing

• Analyzed and communicated audit progress and findings by preparing audit review notes and health plan

approval on recovery findings which averaged from the amounts of $88k to $1million on the assigned

health plans and recommended system fixes on the specific software programs that fall under the

Medicaid plans for Unitedhealthcare defended monthly algorithms or special assigned projects.

• Performed desk audits for state payers and defended reimbursement for Community& State, Medicare

&Retirement reimbursement plans for fraud and abuse in evaluation and management upcoding codes.

• Performed and managed all Medicaid and Medicare audits which involved the specialty, infusion

pharmacy sites in which defended reimbursement for Express Scripts and developed plan of action.

Fanny Flores Page 2

• Priced claims through the Beech Street Network for both HCFA and UB 92 claims for the Florida hospital

healthcare system.

Analysis

• Reviewed monthly reports on CRT finding and reversed and re-entered any claims which needing

adjusting if necessary and to ensure accounts were adjusted accordingly.

• Prepares and responds to data coding analysis requests related to Med Assurant up coding of Evaluation

& Management services for Medicare and Retirement claim based on CMS guidelines for Ingenix

recoveries under United healthcare.

• Worked on unsolicited checks as needed by dept. needs to reach our overall department goals for United

healthcare.

• Managed the denied and improperly reimbursement claims of the Florida hospital healthcare system

claims department and reviewed provider, ancillary, and pharmacy escalation appeals to ensure

appropriate actions were taken.

• Researched and investigated fraud and abuse appeals to ensure proper documentation had been submitted

in order to resolve or uphold the appeal for Medicare and Medicaid United healthcare level of business.

• Reviews provider disputes, Department of Insurance Complaints appeals, contestations and disagreements

regarding Med Assurant down coding of Evaluation & Management services for Medicare and

Retirement claims that are tracked through ODAR using the necessary auditing tools and platforms

(Cosmos, Nice, Oxford, and Diamond, Facets) to ensure the appropriate decision for Optum Healthcare.

• Reviewed information from various offices and other TPA carriers to ensure proper reimbursement was

made within the Florida Hospital healthcare system guidelines using pricing software.

• Increased revenue and profits by 80% for durable medical equipment claims which were in the aging

receivables of 120 days or more by means of research, correct recoding, and appealing the claims for

resubmission if needed for Tandem Healthcare for their 21 skilled nursing facilities.

Compliance

• Accomplished compliance work requirements by orienting, training, scheduling, and guiding other

departments on the requirements of Medicaid and Medicare necessity on appropriate coding and

reimbursement policies per plans for Express Scripts.

• Monitored and updated exposure database on all accruals done for each healthcare pay plan audits that

corresponded to State Medicaid and Medicare plans for Express Scripts.

• Monitored Medicare, Medicare Pt. D, and Medicaid plans to ensure proper reimbursement was being paid

on all claims according to fee schedule or contract specifications for Express Scripts.

PROFESSIONAL EXPERIENCE

UNITED HEALTHCARE, Maitland, FL - Sr. Network Auditor & AR Analyst (2008-current)

EXPRESS SCRIPTS/CURASCRIPT PHARMACY, Orlando, FL - Payer Auditor (2007)

FLORIIDA HOSPITAL HEALTHCARE SYSTEM, Orlando, FL - Claims Supervisor (2006)

TANDEM HEALTHCARE, Maitland, FL- DME Sr. Reimbursement Specialist (2005- 2006)

EDUCATION

Kaplan University - Orlando, FL-undergraduate pursuing Bachelors Degree

American Academy of Professional Coding- CPC,CPMA

Blake Business Institute - New York, NY- Associates Degree Healthcare Administration

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