Customer Service Management

O'Dell Covington, M.S.A.

**** ********** **** *****, ***** Mountain, GA 30087

H 770-***-**** C 678-***-**** ********@*****.***

PATIENT FINANCE EXECUTIVE, REGIONAL MANAGER, ASST. VICE-PRESIDENT

. Strong interpersonal, analytical, problem-solving and writing skills,

with a "take charge" attitude. Comfortable interacting with physicians

and senior management. Strong leadership skills including the direct

management of multiple departments in physically separate locations and

varying work environments, throughout the health system. Working with

Patient Finance, Admission's, Patient Access, Case Management,

Utilization Management, Medicaid, Medicare, Commercial, Managed Care,

and Self pay payors. Experience working with patient financial

services, the hospital based charge description master function and

charge capture process. An in depth working knowledge of patient

access, charge capture integrity of clinical departments as well as the

maintenance of the Charge Description Master (CDM) along with CMS and

other regulatory standards, bylaws, rules and regulations, basic

principles of charge capture, etc. Expertise to collect, analyze,

prepare reports, present information in a comprehensive organized

manner that would be understood at all levels including staff,

managers, directors, senior vice presidents, board members,

etc. Possess knowledge of hospital accounts receivable processes,

hospital department charge capture revenue cycle services and CMS

regulations and must have the ability to communicate verbally and in

writing effectively with all levels of the organization. Demonstrates

ability to effectively manage multiple projects with innovation,

creativity and vision. Investigates and documents develop

opportunities, including software and process development, and creative

problem solving skills. Knowledge in Billing Compliance Federal

Regulations, Experience with PCs, word-processing, spreadsheet,

graphics, and database software applications is desire, Strong

quantitative, analytical, and organizational skills; Ability to

understand medical records, hospital bills, and the Chargemaster;

Ability to utilize and understand computer technology; Ability to

understand all ancillary department functions for the facility; Ability

to communicate orally and in written form; Possesses the ability to

manage team dynamics and consensus building; Possesses a working

knowledge of various payment and coding systems, HCPCS and CPT-4 coding

schemes; Possesses a working knowledge of the UB-92 claim form;

Demonstrates knowledge of the charge development process and the

interrelationship of cost accounting, cost management and related

functions; Understands charging processes and compliance issues and has

the ability to provide resolutions by performing internet research,

utilizing third party payor regulations, referencing coding guidelines,

and referencing local Fiscal Intermediary and CMS guidelines; Possess

the ability to communicate clearly and concisely, verbally and in

writing with knowledge of medical terminology and team-oriented with

strong interpersonal skills

EDUCATION COMPLETED

Graduate Certificate in Finance, Project Management, Data Management, and

Health Informatics, University of North Carolina @ Chapel Hill

Master of Science, Healthcare / Administration, Central Michigan

University, Mt Pleasant, MI

Bachelors of Science, Political Science/ Public Administration, Lander

College, Greenwood, SC

Associate of Science, Human Services / Business Management, Piedmont

Technical College, Greenwood, SC

Atlanta Metro College, Pre-Nursing, Atlanta, Georgia.

PROFESSIONAL EXPERIENCE

SR. Director, Patient Services and Revenue Cycle Services

PPFA/ PPSE, 1/12 to present

White Plains, NY (Head Quarters)

. Coordinates with Medical Director and Practice Management team regarding

staffing, physicians, customer needs. Responsible for the overall

operation of the agency's clinical services programs. Responsible and

accountable for the day to day operations of patient care services and

business operation of the patient care services and health center

operations including preparation and monitoring of the care delivery,

risk and quality, finance, and budget management.

. Responsible for developing the vision for patient access and driving the

direction for the departments and the agency to meet industry standards.

Major responsibilities included day-to-day management, oversight, and

implementation of the entire patient access process in a manner that

meets industry standards. Direct reporting responsibility for the

following areas of patient access, health information management, charge

capture integrity of clinical departments as well as the maintenance of

the Charge Description Master (CDM) for the agency(s). Assured all staff

members are developed, trained, educated and knowledgeable to perform the

necessary function and provide assurance that all governmental and

institutional standards, bylaws, rules and regulations.

. Oversees the agency's billing functions in coordination with the Director

or Revenue Cycle include hiring, handling patient billing issues, and

dealing with regulatory changes related to billing as needed. Overseeing

customer contractual information. Leading and coordinating cross

functional team engaged in billing and associated charge master tasks.

Plans, designs, implements, and enforces billing policies and procedures

as well as streamlines billing processes across multiple divisions from

manual data entry to automated procedures. Strategically plans and

prioritizes short term objectives for the billing department.

. Directs, supervises and coordinates the overall clinical and business

operations for 12 ambulatory health centers in three states. Responsible

for the development and administration of policies on clinical and

business operations. Responsible for scheduling survey preparedness

visits, independent facility visits, review of areas of concerns with

center staff and management. Review of incident reports, operation

reports, and finance reports for all facilities. Manages the overall

billing of electronic and hard copy billing activities, managed care

payer compliance, and follow up. Plans and implements quality assurance

for all billing and customer facing processes. Interfaces with IT

resources to develop detailed implementation plans for billing software

and upgrades, and ensures testing and production timelines are achieved.

Provides billing and technical support to sales and customer service

teams. Insures integrity of customer billings and develops solutions to

special billing requirements

Department of Community Health, 8/1998 to 1/12

Hospital, Medicaid and Clinic Operations

Atlanta, Georgia

Health Insurance Plan Financial Operations Director,

. Oversee billing, accounts receivable and fraud investigations for the

State Health Insurance, Medicare and Medicaid plans. Supervise

collections, audit and reimbursement activities. Responsible for all

systems, technology and tools used during the revenue cycle process.

Coordinate audits, and work with internal and external auditors to

ensure financial and operational compliance.

. Partners and supports leadership across the health plan on assigned

projects ensuring company goals and initiatives are met. Participates

in Operational process improvement initiatives and facilitates

collaborative effort between Health Plan and vendor operations for

implementation. Serves as primary contact to ensure appropriate key

finance and reimbursement operational indicators are in place for

monitoring and analysis.

. Maintains health plan dashboard of key operational indicators

identifies and reports issues to management. Works with management to

identify opportunities for Operational Excellence. Works plan support

staff, managers and account managers to resolve operational issues to

include enrollment, benefit configuration, call metrics,

authorizations, high dollar claims, pended claims, appeals,

adjustments, customer service and policy issues.

. Designs financial/accounting reports for various project tasks.

Performs auditing/analysis on project invoices & monthly actual and

charges. Provides general reporting requests for financial /

accounting reports. Supports Business Units by providing financial

analysis. Communicates w/Bus Units & IT regarding status & progress

of initiatives & current financial status of projects. Analyzes

financial impact on current state of projects. Tracks, controls, and

manages changes. Performs financial audits to project baseline.

Participates in project financial updates and reviews.

. Coordinate, prepare, and review monthly, quarterly, and annual

financial reports, working closely with shared accounting resources

and serving as point person for all internal audit inquiries on behalf

SHBP. Collaborate with internal managers and external clients for

bottom-up development of auditing methodology and associated resource

planning analysis.

Executive Director, Data Analysis and Reporting Unit

. Was responsible for the design and implementation of information

systems required for patient care and allied health services. Served

as the clinical liaison between clinical staff and information

technology staff with the goal of assisting in managing patient

finance and clinical systems functionality; including systems and

process design, systems testing, coordinating problem resolution and

performing required training.

. Worked with clinical staff and department heads to define their

clinical, data, and information system requirements, maps process

models, assists in design of technical solutions to satisfy

requirements, and completes formal system testing. Monitors system

performance and reports anomalies, errors, inaccuracies or

inefficiencies. Ensure training, educating, and instructing end-users

on features, operation, and usage of software systems.

. Responsible for implementation/maintaining all functions of data

analysis/reporting systems and unit, including access, methods and

time, device allocations, validation checks, organization, security,

documentation, and statistical methodology/analysis and reporting.

Directs data analytics and reporting activities across multiple

platforms and environments. Ensures economic and efficient data

availability while maintaining security and integrity. Provides

direction and acts as resource on organization, quality assurance,

maintenance, analysis, and interpretation of demographic and health

data. Responsible for development and enforcement of standards for

design and use of reporting and analytic reports.

. Oversaw and developed business and vendor requirements for

stakeholders, user groups and vendors. Developed and maintained

documentation for assigned projects. Documents and Communicates to

business and vendors about current and proposed process flows for

business and vendor requirements in order to secure commitment in

using these processes which will help reduce risk and ensure a

successful outcome of the project

Division Director, Clinical Services and Patient Revenue Cycle

. Responsible for the overall operation of the agency's clinical

services programs. Responsible and accountable for the day to day

operations of patient care services and business operation of the

patient care services and health center operations including

preparation and monitoring of the care delivery, risk and quality,

finance, and budget management.. Manage the day-to-day operations for

execution of services. Develop document, and implement process

management system to execute services consistently and effectively.

Assisted the CEO and COO in setting measurement to identify

improvements and implement and to respond to any questions on agency's

process, policy and/or procedure.

. Provided leadership and oversight of a comprehensive, efficient and

integrated organization wide Continuous Quality Performance

Improvement program. Measured and assessed performance through

collection, analysis, and trending of data. Focused on processes and

systems to improve performance. Directed, facilitated, and reported

on all aspects of services relating to risk management, patient

safety, and employee health. Directed, supervised and coordinated the

overall clinical and business operations for 18 ambulatory health

centers. Responsible for the development and administration of

policies on clinical and business operations. Responsible for

scheduling survey preparedness visits, independent facility visits,

review of areas of concerns with center staff and management.

. Responsible for maintaining and improving upon the patient revenue

cycle productivity and CDM change processes so that the proper

controls and documentation exist. Developed an audit plans to check

revenue departments' billing practices against the CDM configuration

and associated information systems.

Director, Patient Financial Services

. Was responsible for the daily operations of all the agency's managed

facility-based revenue cycle functions and serves as the on-site

liaison between the facility and hospital. Integrated the departments'

services with the hospital's clinical and ancillary teams, implements

policies and procedures that guide or support service levels, assesses

and improves department performance, and ensures orientation and

continuing education of departmental staff.

. Oversee facility operations of Patient Access functions (e.g.

scheduling, pre-registration, benefit verification, pre-authorization,

admission/registration, financial counseling, etc.) to ensure daily

operations are maintained according to standard

. Maintained and promoted good customer relations with facility

management, physicians and physician office staff. Coordinated with

facility departments/administration teams to manage key revenue cycle

performance expectations and challenges including: upfront collections

protocols, capturing accurate information, timely registration and

patient satisfaction, denial prevention, patient flow, unbilled,

patient concerns, and more

. Review Patient Access performance to ensure timeliness, accuracy,

compliance and standards fulfillment

. Developed and implemented mechanisms and controls to ensure

appropriate billing and payment cycles and accurate and timely

billing, in accordance with established internal and third party payor

requirements. Established and implement appropriate billing policy and

procedures for all billing activities including follow-up on third-

party approvals and collection of overdue patient accounts. Monitored

charge posting, billing and collection operations for compliance with

established policies, regulations, procedures and standards. Managed

actions relating to delinquent accounts, collection agencies, special

adjustments, and/or write-offs. Requested, prepared, and/or maintained

requested reports on billing and collection activities.

. Represented agency at business meetings with billing partners,

Hospital CBO and Third Party Payor, and other related organizations.

Develops and delivers organized, concise yet thorough communications

to the CFO, CEO, COO and executive leadership regarding proposed

changes, developments, and opportunities affecting the organization

and billing department.

. Analyzed reimbursement from all sources, including carrier

reimbursement. Assure maximization of cash collections through

diligent and timely monitoring of all open accounts receivable

balances.

. Maintained and enhanced billing policies and procedures for each

function in the revenue cycle process and ensure staff adherence to

policies. Prepared detailed analyses and reports of billing and

accounts receivable activity and results, including performance

matrixes, bad debt expense and AR days outstanding. Oversaw the

general direction of the patient accounting system and processes,

upgrading and converting. Was also responsible for ensuring the

integrity of the clinic's accounts receivable and that patient

accounts are handled in a timely, courteous and professional manner.

Conducted large-scale design sessions with client executive leadership

in the development of business requirements and best practice workflow

and policies to enhance the patient experience.

. Worked with all Senior Revenue Cycle Leadership to develop and monitor

key performance indicators; discuss trends in Revenue Cycle denials

and develop strategic actions plans. Worked with Patient Access and

Patient Financial Services leadership to ensure effective processing

of self-pay patients; develop an end-to-end solution with the purpose

of reducing overall self-pay AR and the volume of accounts incorrectly

registered as self-pay

Administrative Manager for Ambulatory Services, Primary Care & Managed

Care Services

. Oversee PAS operations of Billing functions, ensuring timeliness,

accuracy, compliance and standards fulfillment as defined in PAS

Service Level Agreements. Provide relevant guidance for Billing

Managers and other PAS Directors to resolve internal and external

issues. Inform PAS COO of any significant issues in the Billing area

(e.g., Billing backlogs, HIM bill drop delays, payer issues, vendor

issues, etc.)

. Inform Billing Management and staff regarding payer requirements,

significant changes and developments. Establish and monitor controls

to ensure appropriate submission and acceptance of electronic and

manual bills. Monitor billed and rebilled summary reports and act on

trends and/or root causes. Monitor PAS billing performance according

to quality and productivity standards developed internally and

documented in SLAs. Complete monthly trending analysis of PAS billing

performance.

. Coordinate and promote implementation and monitoring of standard

master files, processes, reporting and education programs. Follow

overall market trends and communicate significant shifts to PAS

Leadership and others as appropriate. Understand and communicate

nuances of billing various payers such as Medicare, Medicaid, HMO's,

PPO's, IPA's, employers, etc. Oversee management of billing personnel,

providing recommendations for hiring, promotion, salary adjustment and

personnel action where appropriate.

. Assist Solutions Management and PAS Implementation staff in company-

wide initiatives such as the development of operational models,

education programs and national contract compliance. Develop specific

objectives, budgets, and performance standards for each area of

responsibility. Identify and implement process improvements to lower

costs and improve service to facility customers. Assume a lead role

for innovation, knowledge sharing and leading practices identification

within the PAS and among peer group. Perform staff reviews and prepare

performance documents for direct reports.

. Responsible for assuring accurate and complete information was

procured to meet the requirements of registration, medical record

initiation, billing, finance, marketing, governmental agencies and

other strategic initiatives. Ensured seamless patient access and

optimal customer service in all areas of responsibility.

Other past Employment:

March 1996 to May 2011: (PRN; 32 hours per week)

Utilization Review Coordinator,

Grady Health System, Atlanta, Georgia 30310

. Was responsible for the accurate and timely abstraction of core

measures and publicly reported clinical data, reporting and ongoing

medical record reviews. Assisted in data collection efforts for JCAHO

Core Measures and Quality Assessment activities that meet the hospital

accreditation and regulatory reporting requirements. Collected key

clinical findings and other data from medical records for accrual and

aggregate database for use in quality review and utilization

management systems. Assisted management and staff in collection and

processing of QI data.

. Performs utilization review of hospital inpatient areas. Assesses and

interprets customer needs and requirements. Identifies solutions to

non-standard requests and problems. Solves moderately complex problems

and/or conducts moderately complex analyses. Works with minimal

guidance; seeks guidance on only the most complex tasks. Translates

concepts into practice. Provides explanations and information to

others on difficult issues. Coaches, provide feedback, and guide

others.

. Provide telephonic clinical reviews (on units to include ICU, NICU,

CCU, SICU, Medical, Surgical, Trauma, Neurological, Behavioral Health,

and Emergency Departments) and discussions with health care providers

and members to explain benefit coverage determinations and to obtain

additional clinical information. Ensure consistent application of the

clinical coverage review process for all functional components.

Navigate within the claim/Care Coordination systems to obtain

information necessary to make sound clinical decisions on service

requests. Document case review findings, actions, and outcomes in

accordance with Clinical Coverage Operations policy.

. Assess patient's medical necessity by reviewing medical records and

treatment history against Interqual clinical review criteria.

Determines clients' disease management, clinical management, and

medical treatment requirements by evaluating client's current medical

condition. Develop client treatment objectives, and plans.

Establishes treatment programs by setting schedules and routines;

coordinating medical services being provided; arranging resources,

including transportation and escort. Monitors cases by verifying

clients' attendance; observing and evaluating treatments and

responses; advocating for needed services and entitlements; obtaining

additional resources; intervening in crises; providing personal

support. Review of the submitted documentation for proper

identification of the request/claim to verify medical necessity review

or a request that should be routed to another department (appeals,

claims, pharmacy, etc) Receipt of confidential, HIPPA protected

documentation via mail or fax from providers. Serves as initial point

of contact for the providers and members. Updates providers and

members of the status of a request. Logging cases, including all

pertinent information, into the database and updating the status of

each case on the database. Preparing documentation for review by the

internal medical director or an external review agency. Documentation

in the software application and charting systems using appropriate

grammar and according to the Health Plan policies and procedure.

Conducts independent review, research and analysis of requests for

retrospective medical necessity determination with concentration on

prudent standards of best practice and clinical decision sets

(Milliman Care and Interqual guidelines).

. Perform retrospective utilization review of medical and healthcare

claims pended or administratively denied due to lack of medical

necessity determination because Health Plan requirements Retrospective

Review are identification, classification and non-clinical processing

(from initial to final notification) of requests submitted by the

provider for medical necessity determination due to pending or

administratively denied claims. Responsible for maintaining and

updating the database which tracks the status of all cases received

into the department. Providing written and verbal correspondence to

providers, internal medical directors, external review agencies and

members as necessary; admission notification for concurrent review or

pre-authorization were not met. Updates and maintains claims

documentation system for pertinent medical necessity review findings,

as well as, determinations and applicable confinement and service

authorization screens.

. Analyze and monitor quality of care issues to ensure safe, efficacious

care and to minimize corporate risk. Analyze and monitor clinical

records for billing, coding and reimbursement issues. Responsible for

the coordination and maximization of those services that insure

quality of patient care and cost effective utilization of resources.

Participate in a range of quality management activities including

audits, data collection and reporting, and in all activities designed

to comply with CLIA, NCQA, DHR, JCAHO, managed care contracts,

contractual standards and state regulations. Collecting and analyzing

data concerning quality initiatives. Investigating complaints from a

quality perspective.

Emory University Health System, Patient Account Representative, part-time

Data Management Specialist, Patient Financial Resources & Business

Management Unit - full time

Clinical Services Manager St. Joseph's Hospital, Mercy Care Corporation,

Atlanta, GA -- full time

Supervisor, Patient Access, Northside Hospital, ER, (PRN)

Manager, Patient Access Services, Scottish Rite Children's Hospital, ER,

(PRN)

Certifications

Certificates of training:

. Anatomy, Physiology 101 & 102,, Biology 201 & 202, Chemistry,

Microbiology, Pharmacology

. Health Care Statistics and Reports, Management

Objectives/Fundamentals, Continuous Quality Improvement, QI Methods

for a Health Care Setting, Managing Multiple Projects, Project

Management, Fundamentals of Business Writing,

. Delivering Winning Presentations, Microsoft Word, Excel, Access, and

Power Point,

. Revenue Cycle Management for Hospitals and Physician Practices

. Utilization Review and in Case Management

. ICD 9 CM Coding, Advance ICD 9 CM Coding,

. CPT 4 Coding, and Advance CPT 4 Coding. Crystal Reporting, Business

Intelligence, SQL

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