Kimberly S. Himes - 916-***-**** acg4r5@r.postjobfree.com

Objective: To obtain a challenging position in a stable and secure company where I can maximize my medical billing, client service, and management skills.

Skills and Abilities:

Microsoft Office Suite Savvion/Legacy/Facets Oracle software

Typing/10 Keying Insurance Billing IDX/Epic Billing software

Quality Assurance Excel Spreadsheet Data Entry

Front-Office Operations Financial Services Facilitate Training

Accounting/Bookkeeping Professional/Facility billing ICD-9 /CPT Coding

CATS System Lotus Notes Outlook

CIWRS (Compliant Integrated Workflow and Reporting System) Medical Bill Review

Employment History:

Broad-Path HealthCare Solutions- Moda Health 11/2014 ? Present

Enrollment Processor Specialist

? Analyze data to identify trends, opportunities, and potential knowledge gaps in insurance.

? Coordinate with medical facilities such also private practices, assisted care facilities, hospitals, and medical study organizations.

? Determines patient eligibility for care

? Recommend certain health plan programs for treatments that the patient might be interested in.

? Frequently, verifying eligibility for treatments with the insurance companies and then approving the patient for care.

? Seek information where gaps are identified may be tasked with obtaining patient records.

? In charge of enrollment and other forms related to medical care and will make sure that they are filed correctly.

? Telephone and email Members, for enrollment purposes by utilizing primary enrollment forms of communication for the states of Alaska, Oregon and Washington.

? Access member?s pertinent demographics records electronically. Teleworking and helping members to enroll themselves in insurance programs and healthcare programs online. .

? Enter, update, and review data to ensure correct data are available.

? Understand, explain, and document Commercial, Medicare and Medicaid needs.

Kaiser Permanente- Kforce Employment Agency 08/2014 ? 10/2014

Project Coordinator

? Responsible for handling the review process for appeals or denials including investigating, preparing and presenting appropriate MRR (Medical Record Review), over read and coordinate MRR materials for review for grievance panel.

? Resolves member concerns in partnership with internal and external departments while ensuring compliance with regulatory rules and timeframes within mandated timeframes and compliance while providing Quality service effectively.

? Essential Functions: Participates in handling the appeals/denials process.

? Ensures appeals are processed in accordance with regulations, compliance standards and policies and procedures.

? Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.

? Investigates all issues, including collection of appropriate data, preparation and presentation of documents to decision makers

? Informs members or their authorized representatives, physicians and other stakeholders of Health Plan's determinations.

? Collaborates with internal staff, other MS Departments, managers and physicians to seek resolution on issues and cases affecting member while ensuring compliance, documentation and enhancing members' experience

? Ensures integrity of departmental database by thorough, timely and accurate entry * Mentors others in preparation for positions of increased responsibility

? Participates in departmental meetings, trainings and audits as requested * Answer questions and manages existing/open cases

? Top Daily Responsibilities: Coordinating appeals received for hospitals, skilled nursing facility and home health *Writing detailed notices timely and accurately *Processing requests for skilled nursing facility denial letters *Educating regional partners to the appeals process *Interaction with our customers (nurses, staff, physicians) at local facilities (telephonic, electronic).

Blue Shield of California ? Ascent Servicing Group Inc. FTE 02/2014 ? 05/2014

Business Analyst

? Consult and analyzes the business objectives of the stakeholder and develops solutions to their business issues.

? Develops a logical data model.

? Process information analyzes and defines changes to medical plans and provided Quality services effectively.

? Identifies, analyzes, and documents business requirements and delivers work products throughout the project life cycle.

? Ensuring that the recommended solution is both commercial and competitive

? Understanding business requirements and translating them into specific software requirements from Legacy to Facets.

? Understand both technical designs and specifications.

? Analyzing and documenting the required data and information.

? Evaluating information harvested through surveys and workshops, task analysis, and business process description.

? Having strong technical skills, business intelligence, and a full understanding of the needs of the customer.

? Responsible for assessing current healthcare policies in order to determine if they work.

Sutter Physician?s Services ? Account Temps Agency FTE 05/2013 ? 11/2013

Account Representative II

? Review patient bills for accuracy and process claims to completeness and obtain any missing information.

? Knowledge of insurance guidelines especially Medicare and state Medicaid.

? Over read (Medical Record Review)

? Effectively worked with providers, nurses, Case Managers, UM/QM Manager, and Medical Director to ensure system inputs of manual referrals are processed timely, accurately, and within Quality Assurance production standards.

? Follow up on unpaid claims within standard billing cycle time-frame. Follow-up and file Appeals and Grievance?s

? Check each insurance payment is for accuracy and compliance with contract discount.

? Call insurance companies regarding any discrepancy in payments if necessary.

? Identify and bill secondary or tertiary insurances, all accounts are to be reviewed for insurance or patient follow-up.

? Answer all patient or insurance telephone inquiries pertaining to assigned accounts and follow all state regulations.

Coventry Healthcare ?FTE 06/2012 ? 01/2013

WC Integrated Service Specialist

? Interfaces with customers via telephone; written correspondence; fax; web; and or electronic mail to respond to inquiries and resolve concerns; including those of a difficult and challenging nature.

? Responsible for following through and bringing Workman Compensation issues such as appeals and grievance?s to a closure.

? Facilitated and provided training, over read and coordinate all aspects of the MRR (Medical Record Review) and process for appeals.

? Assists with supervisory calls, process enrollment forms, account receivable inquiries, paper claims and/or electronic work queues accurately and efficiently.

? Effectively worked with providers, nurses, Case Managers, UM/QM Manager, and Medical Director to ensure system inputs of manual referrals are processed timely, accurately, and within Quality Assurance production standards.

? Include complex HCFA 1500 UB04 and UB92 forms. Interpret and process difficult adjustments in accordance with company policies and procedures. Review basic pending claims to determine the appropriateness of the claim status and takes necessary action based on status.

? Researched customer inquiries and information by effectively using the Essentials" on-line resource library, Medical Bill Review and Navigator to gather information needed to process the application or customer request or to assemble the documentation needed to process claims and adjustments and in response to inquiries including; but not limited to; TPA?s, authorizations; payments; denials; coordination of benefits; and eligibility.

? Investigates analyzes and resolves outstanding issues to achieve customer satisfaction; accounts receivable or claims payment issues through analysis and evaluation of information and alternate solutions.

? Demonstrate full understanding of all products. Maintains phone and enrollment; accounts receivable or claims quality; and performance levels while working on customer-related and other special projects. Serve as a training resource and mentor to others; particularly new hires.

? Continuously seeks avenues for developing professional expertise. Encourages others to demonstrate professionalism and present a positive image of the company when interacting with customers. Perform other duties as required.

Coram Specialty Infusion Service - FTE 06/2010- 10/2011

Admissions Case Management Analyst Specialist

? Communicated and coordinated with medical professionals and insurance company personnel to expedite patient eligibility. Collect patient demographic via Kodak imaging scanner, retrieved patient medical records and abstract information from the MRR (Medical Record Review) and insurance information on patients over the phone and act as the primary contact for new and existing accounts.

? Investigate insurance coverage to assess patient eligibility, TPA?s, resolve reimbursement issues, sales force and management.

? Effectively worked with providers, nurses, Case Managers, UM/QM Manager, and Medical Director to ensure system inputs of manual referrals are processed timely, accurately, and within Quality Assurance production standards.

? Priced delivery ticket using billing software, such as Legacy and Savvion (RPM). Utilize insurance companies billing grid contracts for pricing. Proficient in Microsoft Word, NCCI, ME, MUE, ICD9. ICD10, CPT, HCPCS, EOB?s, UB92?s, HCFA 1500 and Excel.

? Followed up daily by tracking existing authorizations and make contact with other health care professional case managers to obtain new authorizations for on going Nursing visits and shipment of Medications.

? Check for changes to Private Insurance companies Billing grids and made necessary changes. Develop enhanced reports through the use of computer-based applications by compiling, modeling, validating and analyzing data needed via Excel Spread sheet for new and existing patients.Compile information for reports and support the department where I am needed to meet deadline.

The Golden 1 Credit Union- FTE 02/2005-12/2008

Call Center Rep Analyst I

? Maintained knowledge of Golden 1 products, services, policies and procedures in a call center environment.

? Sold consumer products, Real Estate loans, Equity loans, underwriting, and provided Quality services effectively.

? Identify, investigate, and solve client concerns in a timely manner.

? Prepared a General ledger showing the totals of disbursed funds and approved loans for disbursement.

? Data entry, 10 key, conduct loan interviews, review credit reports, research documents and process information to determine approvals or denials of loan products.

Healthy Families- FTE 12/2002-01/2005

Call Center Eligibility Coordinator Specialist

? Interview clients to obtain demographics and insurance information; including verifying eligibility.

? Processed new member applications, claims, explained insurance coverage, accounts receivable, insurance authorizations and verification. Assisting the uninsured or underinsured in obtaining benefits for the services he/she will be receiving.

? Responsible for ensuring all registration demographics and insurance forms and data entry are complete while providing Quality service effectively to my daily work task.

? Contact patients whose insurance is not valid for scheduled appointment. Assist them to obtain insurance or benefits, as applicable.

? Effectively worked with providers, nurses, Case Managers, UM/QM Manager, and Medical Director to ensure system inputs of manual referrals are processed timely, accurately, and within Quality Assurance production standards.

? Responsible for referrals including data collection, file preparation, response letters, tracking, logs, and follow-up on action plans. Processes logs for the claims department.

? Produces daily concurrent review log to review with nursing staff, UM/QM Supervisor, and Medical Director/ Chief Medical Officer.

? Verified HMO, PPO, Tricare (plans), NCCI, ME, MUE, ICD9, CPT Coding, HCPCS, EOB?s, UB92?s, HCFA 1500 and Excel, medical eligibility, billing, and assured authorizations for medical procedures and treatment.

? Interacted with different clinics/ hospitals to assure the proper completion of patient demographics and insurance information.

NovaCare Physical Rehabilitation - FTE 02/1999-12/2002

Worker?s Compensation/Clinical Lead

? Supported and coordinated a group of 20-25 worker?s compensation representative?s, managed timecards and reviewed audit reports. Foster and promote a team culture of enquiry and learning that enables individuals to openly question, reflect and learn from their practice

? Effectively monitored my team and worked with providers, Adjusters, Case Managers, UM/QM Manager, and Medical Director to ensure system inputs of manual referrals are processed timely, accurately, and within Quality Assurance production standards.

? Provide effective leadership in ensuring that worker compensations practices comply with policies and procedures.

? Researched customer inquiries and information by effectively using the Medical Bill Review software and utilize State reference guides to gather information needed to process claims.

? Assist in ensuring clinical audit becomes part of everyday practice.

? Ensure patient records are up to date and are an accurate reflection of the WC claims follow-up on escalated Appeals and Grievances.

? Facilitated and provided training, over read and coordinated all aspects of the MRR (Medical Record Review) and process for appeals and billing purposes.

? Ensure staff records of sickness and annual leave are accurately recorded and relevant policies and procedures are followed and meeting all guidelines.

? Actively participate in the recruitment and interview process of staff.

? Respond to requests for employment references for team members as necessary.

? Coordinate the daily productivity of billing claim cases, CPT Coding NCCI,, ME, MUE, ICD9, HCPCS, EOB?s, UB92?s, HCFA 1500 and Excel.

? Submit Appeals and request archived bills, Accounts Receivables and Account credit. Billed private insurance, TPA?s, verify eligibility, referrals and authorizations. Correspond with adjusters for billing purposes and Authorizations for treatment.

? Implemented Cal/OSHA health/safety rules and regulations, liaison for company policy questions, and facilitated training.

Sutter Medical Foundation- FTE 01/1997- 02/1999

Patient Service Coordinator

? Coordinated patient visits to see their primary physicians and special procedure appointments. Manually managed medical records and files for the patient service department.

? Responded to pharmaceutical call backs and faxes requests of prescription refills.

? Resolved patient?s concerns in partnership with internal and external departments while following regulatory rules within mandated timeframes and being in compliance.

? Met performance under pressure while balancing the need to produce high quality work related to complex and sensitive patient issues.

? Coordinated productivity of ICD-9 and CPT coding, ICD9, HCPCS, EOB?s, UB92?s, HCFA 1500 and Excel.. Verified HMO, PPO, Medicare/ Medicaid billing and medical eligibility, billing claims, and assured authorizations for medical procedures and treatment.

? Effectively worked with providers, nurses, Case Managers, UM/QM Manager, and Medical Director to ensure system inputs of manual referrals are processed timely, accurately, and within Quality Assurance production standards.

? Investigates all issues, including collection of appropriate data, preparation and presentation of documents to decision makers

? Informs members or their authorized representatives, physicians and other stakeholders of Health Plan's determinations.

? Collaborates with internal staff, other MS Departments, managers and physicians to seek resolution on issues and cases affecting member while ensuring compliance, documentation and enhancing members' experience

? Interacted with various clinics and insurance companies to ensure proper completion of patient pertinent information.

Education:

Western Career College ? Certified Medical Assisting Certificate (GPA: 3.56) AA Degree 09/199 Sacramento,CA Grant Union High School- High School Diploma ? 06/1983 Sacramento, CA

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