Mary Ann Rios

ac0t4g@r.postjobfree.com

623-***-****

Summary

Diversified healthcare claims processing, adjusting and auditing experience, including group, individual, special risk, workers’ compensation, and Medicare and Medicaid reimbursement.

Reviewed medical claims data and/or medical records; identified both examiner and system payment errors in accordance with payer guidelines, provider contracts and state and federal laws; assisted in collections of identified overpayments.

Analyzed audit findings in conformance with payer processing guidelines, provider contracts and all applicable state and federal regulation.

Comprehensive understanding of claims policies and procedures, e.g., eligibility, claims adjudication, claim adjustments, utilization management, policy benefit coverage updates and changes, appeals and grievances and physician/provider networks.

Expertise: Healthcare Finance, PFS, Collections in Commercial Insurance, HMO, PPO, Government, Appeals, Denials, Contract Analyst, Claims Analysis, Workers Compensation, Claims Processor, Auditor, Revenue Cycle Analyst, Consultant, Project Manager, Appeals Analysis, Appeals & Grievance Manager, Quality Assurance, Management, Supervisor, Law & Policy, Legal Business Analysis & Finalizing Claims Audits for Arbitration, Vendor Management, Negotiations of Contracts and settlements with Attorney’s, Behavioral Health & Department of Mental Health.

Professional Experience

Project Manager/Auditor (Contract while finishing my Master’s Degree 2016)

NLB (Next Level Business)-Cigna in AZ, KFORCE-MIHS in AZ

January, 2016 August, 2016 (7 months)

Appeals & Grievance Manager (Managed staff of 52), Data Analysis, Claims Reconciliations, Reimbursement Analysis, Claims Appeals Analysis 1 & 2 Levels, Retro Authorization Appeals, A/R Projects, Credit Balance Auditor, Contract Analysis Specialist, Denial Management Auditor, Claims Auditor, Claims Manager, Quality Assurance, Vendor Management, Claims Processor, Legal Analyst. Finalizing Claims Audit for Arbitration.

Sr. Manager Finance, Collections, Billing & Vendor Management

The Meadows Behavioral Health (Short-term contract assignment while finishing my Master’s Degree)

March, 2014 August, 2014 (5 months)

Manager of Collections (staff of 10), Hire, Train, Staff, Orientation of specific functions, Job responsibilities, Council, Disciplinary Actions, Evaluations, Establish departmental performance criteria, Monitor achievement, Develop management and tracking tools to assess and assure staff productivity, proficiency & efficiency, Operates within staffing and expense budget guidelines, Assign accounts to vendors or attorneys for appropriate handling and closure of aged accounts, Monitor all vendor and attorney progress, Quality Assurance, Develop business office goals to meet facility goals and track accomplishments, Finalizing Claims Audit for Arbitration.

Work with Department of Mental Health, Contract Negotiations & Letter of Agreement and Finance & Data Reporting to CFO direct.

Interim Contracts Specialist (Temp assignment while finishing my Master’s Degree 2016)

Providence, Pacific Hospital, Aurora Behavioral Health College Hospital – Temp Unlimited Agency

Revenue Cycle Analysts /Claims Auditor/Claims Manager/ Claims Processor/ Project Manager /Legal Business Analysts

October, 2012 May, 2017 (3 years 2 months)

Data Analysis, Revenue Cycle Analysts Consultant (Contract) Legal Business Analysts, Commercial Insurance & Managed Care Claims, Revenue Cycle Analysts, Contract Analysts, HMO, PPO, Medicare & Medicaid Collections, Appeals and Retro Appeals, Claims Processor, Work Comp Claims, Hearing Representative, Filing Claims Motions, Negotiator, Claims Reconciliations, Department of Mental Health, Reimbursement Analysis, Claims Appeals Analysis 1 & 2 Levels, Retro Authorization Appeals, A/R Projects, Credit Balance Auditor, Payment Posting, Contract Analysis & Negotiations Specialist, Denial Management Auditor, Finalizing Claims Audit for Arbitration.

Revenue Cycle Analyst/ Claims Auditor/Denial Management

Cedar Sinai Medical Center

April, 2003- March 2012 (8 years 11 months)

Denial Management Auditor & Appeals, Data Analysis, A/R Projects, Managed Care Collections and Appeals, Authorizations and Pre-Certifications (retro appeals), Billing and Coding, Auditing (CPT, HCPCS, DRG, APC), Contract Analysis Specialist, Claims Processor (Epic Software), Medicare and Medi-Cal, HMP/PPO Collections & Appeals, Denials Specialist, Claims Reconciliation & Reimbursement Analysts & Negotiations (LOA), Credit Balance and Refund Auditor, Finalizing Claims Audit for Arbitration.

Patient Finance Consultant Cedar Sinai / Finance Supervisor Del Alamo Behavioral Health

Act One

January, 2000 January, 2003 (3 years)

Revenue Recovery Cycle Collections & Appeals (all payers groups), Contract Analysis Specialist, Managed Care Collections and Appeals, Retro Authorization Appeals, Denial and Reimbursement Analyst, Credit Balance, Payment Posting & Refund Auditor, CCS and Department of Mental Health, Contract Negotiations, Letter of Agreement and Settlements, Financial Reporting.

Appeals, Claims & Billing Specialist

Pacific Alliance Medical Center

January, 1998 January, 2000 (2 years)

Billing & Collections, Claims Denials & Appeals, Contract Specialist & Negotiations, Claims Audit.

Other Experiences

Managing Director Owner Self-Employed

Supper Collection Agency

Claims Appeals, Data Analysis, Collections & Settlement Negotiations, Staff Monitoring (managed staff of 5) Hiring, Termination, Performance Appraisals & Measurements, Coaching & Disciplinary, Training & Cross Training, Hearing Representative with regards to Civil, Workman's Compensation, Subpoenas, Court Deposition, Stipulation, Settlements, Negotiated Contracts, Finalizing Claims Audit for Arbitration, Quality Assurance, Management, Problem Solving, Process Improvement, Evaluations, Disciplinary Actions, Training, and Hiring Orientations.

Education:

University of Phoenix

•Masters Healthcare Management (Graduated)

•BS Healthcare Administration Management

•Human Resource Management & HIPAA Certification

Century School of Law

•Paralegal

•Integrated Revenue Management/Healthcare Revenue Cycle Certification

Specialty Skills/ Qualifications:

•Sr. Manager Collection, Claims, Appeals, Denial Management & Human Resource Management

•Medical-Legal

•Legal Business Analysts

•Claims Auditor, Audit Adjustments

•Contract Analyst & Specialist (all payer groups)

•Claims Reconciliations

•Reimbursement Analyst

•Managed Care Analyst

•Cap Deduction Appeals

•Medicare, Medi-Cal/ HMO PPO Collections & Appeals

•AHCCCS, CCS and Department of Mental Health

•Credit Balance, Payment Posting & Refunds (patient and insurance)

•Authorizations/Pre-Certifications Retro Appeals

• Contract Negotiations, Letter of Agreement (LOA), Settlement Negotiations

•Revenue Recovery Cycle Specialist

•Vendor Management, Vendor Analysis, Vendor Negotiations and Monitoring

•Finalizing Claims Audits for Arbitration

Systems Utilized

EPIC, SMS, AS400, MEDITECH, PARAGON, QUICKBOOKS, SAP, HEALTHLAND, EMDEON, MEDIX, NEXGEN

OUTLOOK, EXCEL, POWER POINT, MICROSOFT OFFICE

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