Sr. Reimbursement Specialist and Certified Coder
Resume:
Denise Smith, CPC
Cell: 310-***-**** ************@*****.***
SUMMARY OF SKILLS
Experienced Medical Sr. Account Receivable & Payable, Collection with 15 + year of experience in healthcare. Strong knowledge of Medical Terminology, Payers and Payors Regulations, Revenue Cycle Management, Coding, Provider Credentialing and Staff Development. EOB Review, Insurance Verification, Denial/Appeals. Authorizations, Payment Posting. Claims: Cms-1500,. Coding Knowledge: ICD-10 & 9, CPT. Software/Practice Management: NextGen, Alteer/Visionary Medical /HER, Advanced MD, Brickell Med-Tex Systems, Real-Med, Total View, Lynx Mobile and Availity. Office Skills: Emailing, Printing, Scanning, HIPPA Compliant, Excel and other Microsoft office products.
PROFESSIONAL EXPERIENCE
09/2002-10/2014- Senior A/R & Credentialing Specialist – 10/2014 – 06/2016-Promoted to: Supervisor, Central Business Office- Arthritis Associates of Southern California formerly known as Pacific Arthritis Care Center), Los Angeles, CA
Accurately complete & submit the following Provider applications (both initial and Re-credentialing/Renewals) as required: 1. Payer Enrollments/Credentialing 2. Facility/Hospital 3. DEA/Medial Licensure. Completion of applications also includes conducting any necessary follow-up to ensure timely completion of process.
Maintain timely and accurate data entry and periodically revise provider data in the Credentialing database; maintain provider paper and electronic data files for provider; use the CAQH system to submit provider data as required by some client plans to credential individual provider.
Initiate and manage new enrollments until providers are enrolled with all assigned payers.
Establish and maintain positive & effective communication with providers, management, clients, and other identified shareholders.
Provide status updates on all credentialing requests to Supervisor and/or provider on a weekly or as needed basis,
Maintain strictest confidentially, adheres to all HIPAA guides/regulations.
Complete and maintain new client provider setup on clearinghouse, CAQH, NPPES, PECOS & EFT/ EDI enrollment.
Update and complete Medicare providers for enrollment through Pecos systems.
Communicate with providers to update them on questions they may have regarding their credentials.
Review proposed contracts and update fee schedules on a quality basis to changes from each payer and make recommendations to the CEO in regards to their participation.
Performs the initial credentialing and re-credentialing functions for all providers, which may include collaborating physicians, Locum Tenens & nurse practitioners.
Maintains strict confidentiality, by all HIPPA guidelines/regulations.
Performs all other duties as assigned by the CEO and Physician.
Fully familiar with Medicare, Medicaid, Commercial & HMO fee schedules, in updating fee schedules in NextGen system.
Responsible for completing Patient Financial Services tasks such as billing and/or accounts receivable follow up with payers and maintaining quality and productivity requirements.
Review payer policies and inform providers of any relevant changes that can impact the group.
Correct claim edits utilizing the Real-med system.
Complete A/R adjustment & other where permitted and appropriate.
Maintain and release all verified claims for third party claim (Commercial, Government & HMO) accounts within established timeframe as assigned.
Follow work list prioritization of accounts as established by department policies and procedures for resolving accounts and/or submitting claims.
Request relevant information from appropriate Revenue Cycle and clinical departments as required.
Process and submit accurate and timely claims to payers, analyze and research unpaid claims, and assist in the resolution of denials and partial payments.
Worked with large volume doctors on daily basis.
Billed out over 2M monthly; Knowledge of Managed Care, Medicare, Medi-cal, Medi-Medi, HMO and Commercial Plans.
Collect revenue by reminding delinquent accounts, notifying customers of insufficient payments.
Resolves account discrepancies by investigating documents; issuing stop payments, payments and adjustments.
Updates receivables by totaling unpaid invoices.
Protects organization’s value by keeping information confidential.
Summarizes receivable invoice & claims account; coordinating monthly transfer to accounts receivable account; verifying totals; preparing report.
Posts customer payments by recording cash, checks, and credit card transaction to GotoBilling software system.
Post EOB payments from all payers to NextGen system.
Make necessary adjustments to patient demographic, insurance, and account balance information.
EDUCATION
Certified Professional Coder (CPC), 2006, American Academy of Professional Coders
Medical Assistant, (1991), The Bryman School, Phoenix, AZ
Business Management, (1983), Gateway Community College, Phoenix, AZ
General Studies, (1974), High School Diploma, Phoenix Union High School, Phoenix, AZ
PROFESSIONAL ORGANIZATION AFFILIATIONS
American Academy of Professional Coders (AAPC)
AAPC Certificate of ICD-10-CM Proficiency
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