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Epic Resolute Hospital Billing Analyst

Leander, Texas, 78641, United States
January 11, 2018

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Benjamin G. Galicia

*** ****** ***** **.

Leander, TX 78641 Cell: 325-***-****

6+ years as Certified Administrator in EPIC Resolute Hospital Billing with 2015 New Version Training and 6+ years of build experience in EPIC RHB Claims. Experienced in many aspects of healthcare reimbursement methodology and revenue with expertise in HMO, managed care, compliance and claims processing. Strong understanding of reimbursement methodology with expertise in HMO and managed care. I have a proven ability to maintain compliance of policies and practices in the health care industry. Solid experience acquired in working with large national entities. Highly motivated self-starter. Strong management and leadership skills with attention to detail. Excellent communicator with emphasis on building strong client relationships and providing thorough customer service. Demonstrated success in knowledge of insurance policies/procedures by auditing and directing co-workers to organizational resources. Deep understanding of how technical implementations and business functions are impacted during organizational change. Possess diverse managed care experience in big industry, which contributes to problem resolution in various situations. Manage staff in day-to-day duties such as insurance collections, follow-up, appeals and denials. Thorough analysis of claim denials and subsequent appeal resolution. Experienced in resolving a variety of issues including coding and claims issues as well as Epremis billing issues.

Qualification Highlights

EPIC Certified RHB

EPIC HB Claims Experience Extracts/Report Writing System Build/Configuration

RHB Subject Matter Expert

Mathematics Degree Analytical Skills Problem Solving Skills

Contract Interpretation Reimbursement Methodology Administration Skills Management Skills

Additional Skills

Claims Processing

CDM/Charge Router Build HMO Compliance Training/Mentoring

Benefits Interpretation

Claims Auditing Managed Care Compliance Account Management

Compliance Auditing

Contractual Adjustments Appeals Resolution Recoupments

Professional Experience

Baylor Scott & White Health, Dallas, TX / Avaap USA. March 2017 – January 2018

EPIC Resolute HB Sr. Analyst / Consultant

EPIC Resolute HB Sr. Analyst for the largest not-for-profit health care system in Texas.

Completed the optimization of 4 initiatives for hospital billing: S.A.N.E. billing, Inter-Company purchased services, Cash management/deposit splitting and Revenue Guardian build.

Moved their S.A.N.E. workflow from paper records and billing outside of EPIC into all electronic in EPIC.

Built Inter-Company purchases services which will allow revenue and A/R to reside in one facility when a patient who is admitted to facility A is sent to facility B for additional services.

Cash management was built to move the process of splitting bank deposits from a third party vendor into EPIC.

Optimized the Revenue Guardian build in EPIC to ensure maximized revenue is captured.

St. Francis Medical Center, Cape Girardeau, MO / Boston Services

EPIC Resolute HB Analyst / Consultant October 2016 – March 2017

EPIC Resolute HB Analyst for facility which had initial go-live on 7/1/16.

Currently specializing in extract rebuild and report scheduling for HB and PB.

Example update includes HB And PB self-pay accounts which were being sent to their self-pay collection vendor had incorrect data from their go-live date. The vendor was “missing” 30,000 of the 35,000 accounts which had been assigned to them since 7/1/16. Completed rebuild in 3 weeks.

Have updated 6 major extracts and run catch up files for all reports from 7/1/16 to bring all reporting data current for those specific reports. Reports include self-pay data, as well as state required hospital reporting data.

Benjamin G. Galicia Page 2

Driscoll Children’s Hospital, Corpus Christi, TX

Patient Financial Services Manager November 2011 – October 2016

Driscoll Children’s Hospital is the premier children’s hospital of the Texas Coastal Bend and Texas Valley.

EPIC Certified Resolute Hospital Billing Administrator with extensive knowledge of the EPIC billing system.

Built contracts that pay by DRG, percentage of billed charges, grouper rates, case rates, global case rates, per diem and contain lesser of and stop bill language, for use in expected reimbursement calculations.

Built multiple extensions, components, work queues, work queue rules, extract reports, billing indicators, collection agency indicators, security classes and collection agency extracts among other builds.

Sole owner of the hospital’s EPIC Resolute Hospital Billing system.

Query data using different criteria/parameter options and building reports without the use of templates or models.

Create multiple reports using various systems such as EPIC and Business Objects, setting up some reports to automatically run and send results to specified recipients.

Manage 12 employees including 1 supervisor, 1 billing specialist, 1 claims analyst, 1 QA specialist, 1 customer service rep and 7 payer follow-up representatives.

Primary responsibilities include overseeing timely filing of clean claims, timely follow-up of outstanding claims and collection of outstanding revenue owed by payers.

Daily activities include assisting follow-up reps with questions, correcting account billing issues, approving adjustments, reversing/initiating billing of claims, working multiple work queues and EPIC configuration.

Other responsibilities include overseeing timely filing of clean claims, timely follow-up of outstanding claims and collection of outstanding revenue owed by payers.

Work closely with PFS Director to plan and implement department improvements, such as increased billing acceptance rates, increased cash collections and increased automated account resolution, all to increase department efficiency.

Also work closely with VP of Finance, Hospital Contracts Negotiator, HIM, Registration and Accounting.

Superior Health Plan/Centene Corp., Corpus Christi, TX

Provider Relations Representative November 2010 – November 2011

Superior Health Plan, a subsidiary of Centene Corporation, is a Texas Managed Medicaid payor.

Was the VIP provider representative with a coverage area extending from the entire Houston area, west to Laredo, and down in the Valley due to efficiency and performance.

Primary responsibility of resolution of provider issues both in person and telecommunication. Issues included incorrect claims processing, incorrect provider setup and recoupment resolution. Visit providers and make outreach calls each month to maintain provider satisfaction.

Provider education through face-to-face orientations, both in a large group setting and individual office environments. Conduct online webinars and other education methods.

Submission of projects to resolve claims issues after conducting thorough research to determine claims required additional processing.

Experience working directly with hospital and physician billing office and finance staff to ensure resolution of hospital and physician issues. Worked closely with contract negotiators and billing office management on multiple issues including overpaid/underpaid claims, stop loss interpretation, recoupments and authorizations.

AIM Healthcare Services, Inc. /United Health Group, Franklin, TN

Regional Account Manager January 2010 – October 2010

AIM Healthcare is a subsidiary of United Health Group.

Resolution of credit balance accounts at regional hospitals.

Drafting refunds to third party payers and/or the guarantors, requesting necessary adjustments.

Monitored/Maintained compliance with all applicable state and federal regulations to validate proper reimbursement and contractual compliance.

Experience at Driscoll Children’s Hospital included managed care entities such as TRICARE, Texas Medicaid and Healthcare Partnership (TMHP), Superior, and Driscoll Children’s Health Plan (DCHP). This allowed me to utilize my knowledge and experience in the managed care area of insurance as well as compliance statutes and regulations.

Benjamin G. Galicia Page 3

Blue Cross Blue Shield of Texas, San Angelo, TX

Auditor/Appeals Processing/Customer Service January 2006-January 2010

Main responsibility prior to resigning was an auditor. I audited telecommunications and correspondence for 15-20 representatives. Each representative was audited 7 times per week. I ensured correct information was given on calls and letters given to providers and members. If incorrect information was given, it was my responsibility to advise the representative of their error and provide documentation to show the representative where the correct information was so they could improve their skills and prevent future errors. During my time with BCBS, my duties required continuous monitoring and compliance with internal as well as federal and state regulatory statutes.

Written correspondence, handling provider and member appeals, policy updates, etc. Providers usually appeal underpayments and members have a wide variety of requests such as address changes, ID card requests, payment reviews and provider questions. I took the needed steps to research and determine the outcome of the provider’s or member’s concern then sent a letter to advise the inquirer of the resolution.

Worked in PPO/POS/Traditional plans and main product HMO segment

Assisted members and providers with benefits, eligibility, and claims inquiries. Provided thorough and accurate information on benefit availability, eligibility, and claim payments/denials.

Processed claims including determination of payment/denial.

Claims adjustments and authorizations of incorrectly paid or denied claims.

Sitel Corp., San Angelo, TX

Customer Service/Management September 2002-December 2005

Acting manager from August 2003-May 2004.

Promoted to full time manager in May 2004 to oversee a team of 15-25 agents.

Responsible at times for up to 40 agents.

Updated representative’s statistics daily and weekly to make them aware of productivity levels.

Conducted daily individual coachings to help agents improve performance and productivity.

Responsible for calls escalated to supervisor level by upset customers.


Angelo State University

Bachelor of Arts Degree in Mathematics with minor in Business Administration

Will pursue continuing education in necessary field, when needed or requested by employer.

Computer Skills

Proficient in all Microsoft Office Applications, Dashboard, EPIC, AS400, Business Objects

and various other hospital programs and computer systems

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