Medical Insurance

Mrinmayee Kalwal

Torrance, CA *****

916-***-****, ********@*****.***

Professional Summary

Highly experienced in Healthcare Claims reimbursement process for 6+ years & Medical Billing for 2 years

Detail oriented quality focused professional Claims Analyst and Medical Billing Clerk

Successful track record handling complicated assignments

Detailed training in managed care plans and insurance types, 3rd party payer requirements (including Medicaid/Medicare), and information to cover the various inpatient and outpatient prospective payment systems including: fee-for- service, managed care, home health, DRG, self-pay and retrospective payment systems

Claim analysis of coding and billing compliance, potential third-party liability, accurate coordination of benefits (COB)

Benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity

Claim investigation as appropriate

Handled facility claims, Hospital claims, Medical claims, and Dental claims

Experienced in reconciling insurance and patient payments and resolving account disputes and payment posting

Proficient in a variety of practice management software applications

Dedicated to maintaining strict patient confidentiality

Effectively manage set priorities, work independently, complete multiple projects within established deadlines

Available to interview and start immediately

Skills

Medical Terminology

Knowledge of ICD-10-CM/PCS and 5010

HIPAA and Patient Confidentiality

Knowledge of Cafeteria plans

Knowledge of FMLA, COBRA

HMO, PPO, POS, EPO

Collections and Charge-Entry

Insurance Verification and Follow up

Account Corrections: write offs, duplicate charges

Claim Adjudication and Reconciliation

Medicare Plan

Claims Submission and Claims Processing

Knowledge of Insurance and 3rd Party Payers

Claims Appeals for denials

Account Research and Analysis

Pre-Authorization/Pre-Certification

ICD-9 and CPT Code Verification

MS-DRG Assignment

Professional, reliable, and trustworthy

CMS 1500 and UB-04 Claim Forms

HCFA and UB forms

Payment Posting and EOBs

Computer Literate; Microsoft Office Suite

SEQUEL

EDIX12

Salesforce.com, service cloud

Quickbooks

OfficeAlly

Allscripts

Kareo

Plexis

AdvancedMD

AMISYS

NEXT LEVEL EXETER

Education

Medical Billing - Career Step May 2016

Certificate of Graduation

Coursework includes: Medical Terminology, ICD-9 and CPT coding basics, EHR / Medisoft training.

Detailed training in claims processing, claims submission including EOB/payment posting, charge-entry, collections, insurance verification, appeals for denied claims, collections, pre-authorization, and account resolution.

Practicum experience includes filing CMS 1500 and UB-04 claim forms, and use of actual medical records to identify discrepancies in reimbursement.

Information about ICD-10-CM, ICD-10-PCS, and 5010 implementation, patient confidentiality, documentation, and insurance follow up procedures.

Detailed training in managed care plans and insurance types, 3rd party payer requirements (including Medicaid/Medicare), and information to cover the various inpatient and outpatient prospective payment systems including: fee-for-service, managed care, home health, DRG, self-pay and retrospective payment systems.

Master in Education – Andrews University March 2006

Experience

Dell, Inc., Healthcare Claims Examiner (Contract position) 07/2016 – 01/2017

Adjudication of claims for the Health Plans lines of business. Primary duties include analysis and resolution of claims, including coding principles, benefits, pricing and potential third party liability. Handling Claims compliance with state, federal and contractual requirements. Resolve complicated claim issues and identify appropriately when to escalate issues for review. Claim analysis of coding and billing compliance, potential third party liability, accurate coordination of benefits (COB), benefit application including limitations and restrictions, pre-existing conditions, subrogation, medical necessity and other claim investigation as appropriate. Handling facility claims, Hospital claims, Medical claims & Dental claims. This was an WAH experience.

Applications – AMISYS, AMISYS Advance, AMISYS Release 4 and 6, NEXTGEN

The Apollo Clinic & Apollo Hospital, Medical Billing Clerk (Full time Position) 03/2013 – 02/2015

Schedule appointments & Claims submission - Schedule patient appointments (20-30 patients per day). Collect correct Patient’s demographic & insurance data to submit claims on time. Update all files including insurance companies, diagnosis, procedure, fees/profiles. Followed the guidelines and be in compliance with local, state laws and regulations. Ensure claims are entered and submitted within 48 hours of appointment date.

Accounts Receivables (AR) - Reviewed billing edits and provided insurance company with correct information. Reviewed claim denials and payer requirements for corrective action and prevention in the future. Corrected and resubmitted claims denied by insurance company. Identified account discrepancies and issues that hindered claim payments. Post and reconcile insurance and patient payments. Research and resolve incorrect payments, EOB rejections, and other issues with outstanding accounts.

Retrieve Electronic Remittance Advice (ERA). Processing of patient’s monthly statements. Answer calls and resolve patient billing inquires. Follow up on Insurance and patient aging. Re-submit insurance claims as necessary.

Posting adjustment to patient account once office sent overdue account to collection agencies - Locate the correct patient ledger in the computer. Enter the adjustment as a debit or a credit. Post the payment, choosing “collection payment” as the payment source. Enter any adjustment due to collection agency fee if applicable.

Automatic Data Processing Inc., Healthcare Claims & Worker Compensation Analyst (Full time position) 12/2006 – 02/2013

Data entry – EE & ER enrollment annually into internal benefits application (SAM).

Load EE & ER data electronically via EDIX12. Leave management & COBRA information.

Healthcare claims entry into internal application (Kofax Validation, OCR). Adjudicating these claims as per IRS regulations. Target per day was 800 claims. Mail denial letters for additional information.

Appeals entry & Adjudication into internal Appeals tool. Target per day was 30 appeals Mail/email appeal resolution letters. Educate the employee about the claims process. Contact medical provider(s) and review the medical treatment plan. Discuss a plan for return to work with the employee.

Auditing – Audit claims, appeals, high dollar amount claims, duplicate entry, ineligible denial claims and overpayment claims.

Reports – Generate on various error reports (Duplicate claims, Overpayments, Ineligible claims payment, Incorrect denials) & account related reports (EE account balance, annual goal, deduction, per paycheck deduction. ER contribution, ER bank account detail, Leave & absence report). Developed internal audit reporting and metrics of plans, including FSA forfeitures report.

Research & process improvement – Strong knowledge of Managed care Insurance payers. Developed a strong understanding of insurance policies and legal issues. Analyze data, identify trends, and troubleshoot issues that impact claims benefit payment. Identified process improvements and automation opportunities which helped in reducing cost & man power. Provided a series of back to basic training to claims department. Participated in internal & external auditing system integrations.

Supervision - Supervised & executed process improvement action plan. Ensure data integrity, including data accuracy, timely data entry & make approval or denial decisions. Ensure SLA quality of 99%.

Excellent in User Acceptance testing (UAT). Review & validate and test cases. Played role of Team Lead of FSA Claims team & User Acceptance testing (UAT).

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