Customer Service Medical

VANESSA HILL, M.H.A

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

AURORA, CO 80013

PHONE: 303-***-****

***********@*****.***

Qualifications

o Experience with Manage Care, Medicare, and Medicaid

requirements, Federal, State government requirements and

policies.

o Healthcare contract analysis experience.

o Experience with CMS policies, procedures, forms and website

research.

o Experience with Kaiser Permanente, Rocky Mountain Health,

Cigna, Colorado Access, Aetna, Pinnacle, TRICARE,

UnitedHealth Group, Humana health plans.

o Knowledgeable with HCPC, CPT4, and ICD-9-CM coding

methodology Experience in health claims auditing, electronic

billing practices, medical policy and benefit interpretation.

o Excellent problem solving and analytical ability.

o Ability to act independently, implement defined objectives

and work in a collaborative team based environment.

o Strong organizational, oral, written, interpersonal,

communication skills.

o Proficient in Microsoft Suite applications.

Education

Webster University

Degree Program - Health Administration (MHA)

Graduated December 18, 2010

Columbia College

Degree Program - Business Administration (BBA)

Graduated July 28, 2007

Experience

October 2009 - Present CNIC Health Solutions Greenwood

Village, CO

Auditor / Claims Support

Scope / Key Responsibilities: Works as part of the Claims

Support group and help to meet the demands of the entire

team. Show respect for differences and diversity; understand

responsibilities and interdependence of team members and

colleagues. Provide appropriate and timely customer service

in accordance with the Mission and Values of the company.

. Supports corporate objectives by utilizing detailed knowledge

of claims procedures, policies, billing, contracts and

benefits to perform timely and accurate research for the

retraction and adjustment of claims. Provide administrative

support and assistance for external audits as needed.

. Review claims inquiries and reports to be retracted, adjusted

or reconsidered.

. Researched and reviewed member information on various reports

to retract claims that were paid inaccurately (e.g.,

member terminated).

. Completed all steps involved in retracting, adjusting or

reconsidering claims including reporting necessary co-

pay information to Finance to ensure accurate accounting of

the claims system.

. Used individual thought to develop, organize and evaluate

data to resolve problems.

. Used judgment to determine a course of action. Precedents and

assistance are available as resources.

. Consistently exceed minimum standards for quantity, quality,

job knowledge and dependability. Take the initiative to

identify potential setbacks in advance and seek out

necessary alternatives or solutions. Share knowledge for the

benefit of the team and be a role model for others.

. Utilized spreadsheet programs to input, update, and maintain

data. Generated reports as necessary. Performed queries

and create ad hoc reports. May also work with IS to have

necessary reports produced.

. Processed special claims, which may include non-network

discounts.

. Assisted external auditors, groups, and brokers with claims

research and related documents.

. Other functions may be assigned and management retains the

right to add or change the duties at any time.

June 2008 - September 2009 Lockheed Martin Aurora, CO

Health Economic Analyst

. Analyzed provider contract requirements for the dental care

branch program according to provider's contract, utilizing

government policy manuals.

. Provided interpretation on contractor performance

requirements in the Performance Assessment Tracking

System, by validating non-compliance and advised Contracting

Officer Representative.

. Managed contract transition requirements, developed

transition and phase in schedules, and submitted weekly

transition status report.

. Reviewed marketing materials, provider's website, member

educational materials, benefit booklets, and quarterly

provider articles and recommended any additions or changes.

. Reviewed, evaluated and disseminated weekly, monthly and

quarterly utilization reports submitted by the dental

contractor.

. Coordinated the re-contracting process, including Request for

Proposal, response analysis, and contract negotiations for

the contracting officer representative of the dental care

branch program.

October 2007- June 2008 Kaiser Permanente Aurora, CO

Quality Auditor

. Completed monthly, quarterly grievance audits for Medicare /

non-Medicare complaints.

. Provided a summary of results outlining general observations,

trends, best practices, gaps, risks, and action plan for

quality, training and recommendations for action items for

operations manager.

. Completed routine audits on QA auditors for Member Service

Liaison Team and provided ad-hoc audits based on

identified gaps.

. Provided support to Regional and National Compliance region

by conducting mock audits to improve calibration and

accuracy of audits.

. Utilized audit findings to refine old processes or determine

implementation of new processes to assure future

accuracy.

. Participated in cross-functional teams to develop, refine

processes to improve quality.

Member Service Liaison

. Responded to Member Services telephone and written complaints

from all plan members.

. Contacted Consolidated Service Center when required regarding

membership issues.

. Contacted Patent Billing Services when required regarding

patient accounts.

. Documented all members/patients complaints by actively

seeking information to understand member/patient

circumstances.

. Provided appropriate financial service recovery to member,

hospital, physician, or other medical facility.

. Developed and maintained contact with key department

individuals in research and resolution of complaints to

insure timeliness of resolution according to required

timeframes.

. Researched, confirmed and issued benefit payment and medical

necessity adverse determinations denials.

September 2001 - October 2007 University Physicians Inc.

Aurora, CO

Senior Specialist

. Researched and resolved complex CPT4 / ICD-9-CM 9 coding

issues.

. Prioritized, organized and evaluated Medicine Department

billing and coding issues and recommend solutions for

identified problems.

. Performed payment analysis of physician reimbursements on

billed CPT codes according to provider's contract with

insurance carriers.

. Recommend efficiencies to overall departmental processes to

management by documenting all training and procedures.

. Performed periodic reviews of outstanding unresolved patient

accounts in PCS work files.

. Assumed responsibility for coding, data entry, and correction

of data in computer database system.

Denial / Payment Specialist

. Analyzed, researched and appealed denied claims for Medicare,

TRICARE, United Healthcare, Cigna, Aetna, Humana and

other insurance carriers.

. Reviewed invoices for correct coding requirements for

reimbursement.

. Provided supporting documentation for appeals process,

account research, reconciliation, and account analysis on

assigned departments.

. Analyzed, researched, resolved and appealed low and incorrect

payments according to provider contract for government,

commercial, and managed care plans.

. Referred Fee Schedule Methodology to the Product Application

Analyst for correct loading in IDX Bar Pricing Module

Fee Schedules and PMMC Physician Pro contract and pricing

information.

. Analyzed new and updated contracts to determine payment

schedule for uploading into both Physician Pro and BAR

Pricing Module.

. Maintained updates for Physician Pro and BAR Pricing Module

data.

. Worked as a liaison between Patient Accounts and Marketing to

communicate contract discrepancies.

. Worked with Provider Representatives to resolve any payment

or contract issues.

May 2000 - August 2001 Colorado Access Denver, CO

Claims Auditor

. Audit adjudicated HCFA-1500 and UB92 medical claims by

provider specialty and claims processors.

. Utilize audit results and feedback from other departments to

identify training needs.

. Provide feedback to Claims Management to determine

development needs within Claims Department.

. Report audit error percentages to management through excel

applications.

. Document audit findings accurately in the units audit

application system.

Contact this candidate