BARBARA DANIELS

**** ******* ******

Pittsburgh, PA 15208

412-***-****

acqzdu@r.postjobfree.com

Education: Carlow University, College of Business Administration

Bachelor of Science in Management Health Services 2014

Community College of Allegheny County, Pittsburgh, Pennsylvania

Associate in Science, Liberal Arts & Science Degree 2000

Relevant Coursework:

● Strategic Planning ● Data Management Systems ● Management Information

● Financial Management ● Accounting ● Human Resource Management

● Business Communication ● Business Law 1& 2 ● Concepts in Healthcare Finance

Relevant Skills:

● Microsoft Office ● Data Bases SQL Query ● Power Point/Excel Spreadsheet

● Teamwork ● Negotiations ● Attention to detail

● Customer Service ● Problem Solving ● Benefit Plans

Work Experience:

Billing Specialist II, UPMC Physician Services, Pittsburgh, PA 12/2014-

● Ensure efficient processing of denials and appeals.

● Work with the payors and subscribers to resolve issues and facilitate prompt payment of claims.

● Participate in review and evaluation of claim details to ensure appropriate reimbursement.

● Participate in assessing claim edits to enhance the billing system functionality and identify user

Training and development needs.

● Assess and monitor workflow volumes on an ongoing basis during the growth and development of

the billing department to ensure optimal performance of staff.

● Assist with identification of problems related to the department and reporting such to the Manager of

Billing with a proposed solution in a timely fashion.

Managed Care Financial Services/Appeals Specialist, Advance Sourcing Concepts, LLC, Pittsburgh, PA 6/2014-11/2014

● Appeal Preparation for multiple levels and multiple types of appeals for incorrectly paid claims.

● Interpret Medicare Regulations and Guidance.

● Establish Ongoing contacts within the Complaints, Grievance & Appeals Department at Health Plans.

● Write letters to Maximus when Health Plans are out of compliance with

the Medicare guidelines for processing the claims correctly.

● Write letters to Office of the Regional Administrator when Health Plans are out of

compliance with the Medicare guidelines for processing claims correctly.

● Recovered over $1,300,000.00 dollars of unpaid claims from 2012.

● Research changes and updated to Insurance Plan-Specific Claim and Appeal Processes and

requirements.

● Review and resolve remittance errors and claim rejection from payors.

Internal Adjuster/Research Support, UPMC Health Plan, Pittsburgh, PA 4/2011 – 10/2012

● Adjusted HCFA/UB claims to pay the correct amount according to member’s benefits plan.

● Processed approximately $75,000,00 on a monthly basis.

● Audited COB spreadsheet claims on a monthly basis to determine if we were primary, secondary or

tertiary.

● Adjusted Medicare ambulance claims in the amount of approximately $50,000.

● Entered paper HCFA and UB claims entering ICD9, CPT or HCPC codes.

● Adjusted the ineligible members monthly report and the duplicate monthly report.

Claims Processor/CSR Highmark/HM Benefits Administrators, Pittsburgh, PA 8/2006 – 10/2010

● Paid HCFA/UB claims according to member’s benefits plan. Processed

approximately $200,000,00 on a monthly basis.

● Investigated overpayments on claims, sent a letter requesting the refund to be paid or I would offset

the claim.

● Entered paper HCFA and UB claims added ICD9, CPT, HCPC codes, diagnose and codes.

● Adjudicated electronic claims after verifying that the procedure is an eligible benefit.

● Approved or denied medical claims based on medical documentation.

● Calculated the members ‘deductible, Out of Pocket, Life Time Maximum and applied to the claim.

● Explained the benefits to members and including providers, including how claims were processed.

Eligibility Coordinator, YWCA of Greater Pittsburgh, Pittsburgh PA 6/2004 – 7/2005

● Interviewed and counseled clients for the purpose of obtaining, recording, evaluating and

determining eligibility.

● Planned, organized, processed and managed case loads of up to 300 individuals to ensure timely

eligibility.

● Counseled clients on their rights and responsibilities as recipients of subsidized child care benefits

through individual conferencing, phone communication and by written correspondence.

● Achieved high performance standards as prescribed by the Pennsylvania Department of Public

Welfare while providing quality customer care.

Intracorp, Insurance Health Services, Pittsburgh, PA 1/2003 – 9/2003

● Built the case assigned the correct ICD-9-CM, CPT-4 or HCPC codes.

● Interacted with surgeons to accurately acquire preauthorization for surgical procedures.

● Approved or denied Physical Therapy visits according to members benefits.

Contact this candidate