Medical Fraud Investigator, DME Authorization, Managed Care
Resume:
Melissa Ann Bailor
Carlisle, PA 17013 US
Mobile: 717-***-****
Email: acqvyp@r.postjobfree.com
SUMMARY: Self-motivated leader seeking opportunity to use her extensive
insurance background and knowledge to enhance relationships with facilities,
physicians, and ancillary providers.
Experience:
ompany Confidential
C
2007 2011
Medicare Fraud Investigator (Federal Contractor)
I was one of 6 Medicare Fraud Investigators who worked as a contractor for the
state of Pennsylvania. Our agency cooperated with other health and law
related agencies to ensure providers understood how to correctly bill
Medicare. We educated providers about how to use Medicare in their practice.
We also worked with law enforcement to procure Medicare monies that had
been billed incorrectly and needed that to be returned to the insurance
companies.
Responsibilities included:
* Complete provider analysis through Lexisnexis and other confidential
searches.
* Provider data analysis.
* Familiarity with Highmark Medicare rules and regulations
* Familiarity with Federal Medicare Rules, Regulations,Sections and
Subsections as they applied to Medicare providers, Medicare Offices and
Medicare billing
* Onsite visits to Medicare providers and Medicare subscribers
* Investigations into suspected aberrant Medicare billing practices and
Providers.
* The ability to work independently
* Request medical records
* Perform confidential job specific requirements of fraud investigation
* Familiarity with Federal Medicare Rules, Regulations, Sections and
Subsections as they applied to Medicare providers, Medicare Offices and
Medicare billing
* Onsite visits to Medicare providers
* Investigations into suspected aberrant Medicare billing practices and
Providers.
* The ability to work independently
* Request medical records
* Perform confidential job specific requirements
Background checks cleared on local/state/federal levels, security clearance
granted.
Health America
2007
DME Authorization Representative
The primary responsibilities of this job were to provide physician requested
DME equipment to all qualified Health America subscribers. I took phone calls
from physician offices for DME equipment for their Health America customers.
After verifying that the Health America insurance was valid and the customer
had DME coverage, I spoke with the requesting physician’s office on the
phone. The customers information was inputted into a computer template that
was Heath America specific, but relied on HCPC codes, DX codes and ICD-9
codes. Depending on the dollar amount of the item being requested, plan
exclusions and other criteria, I may have worked in tandem with case review
nurses or physician review board.
Critical Care Systems
2004 2007
Medicaid IV Drug Reimbursement & Authorization
The primary responsibilities of this job were to act as a Medicaid
reimbursement specialist. I was responsible for authorizing IV therapy through
the Pennsylvania Medicaid system. This included Gateway, Three Rivers,
Health Mate, Amerihealth Mercy, and Regular Medicaid. I had to authorize the
IV therapy and each individual drug. This was accomplished by working with
the ordering physicians office order, the members insurance coverage, and
using HCPC codes, DX codes and ICD-9 codes.
PinnacleHealth
1993 2004
MED/SURG:
My job responsibilities were direct patient care. I was responsible for patients
before and after the went to the OR on the floor. I worked all three shifts so job
duties varied. They included but were not limited to: OR Prep, I&O, PT
charting, blood sugar monitoring, wound care, vital signs, SOAP note, EKG.
CPR certified basic adult.
Labor & Delivery:
My job responsibilities included direct care of pregnant patients 18 weeks and
greater. I worked night shift but was on-call for 16 hours every pay period. My
duties included but were not limited to: Basic care of patients admitted to
L&D, I&O, preparing the patient for both vaginal and C/S delivery, Preparing
instrumentation tray for vaginal and C/S delivery, OR preparation(3 rooms),
stocking of supplies, stocking of OR instrumentation, ordering supplies from
Central Sterile Processing(CSP), checking/replacing medication in OR rooms,
checking and ordering suture in OR rooms, shift check of crash cart/charging
joules, preforming EKG, care of women postpartum, care of newborns, care of
stillborn infants, sterile technique, suturing.
SPECIAL SKILLS: Daytime OR training. I worked in the OR and short procedure
to gain experience. When an emergency surgery was called for on the L&D
floor, I could set a case, scrub and be able to open skin in 5 minutes. I am well
versed in sterile procedure and assisted in many OR procedures. I also know
how to close skin with both staple and suture. CPR certified in advance
adult/child/infant
Speech & Hearing Dept./ENT Clinic
My job duties included direct patient care and preparing charts for the ENT
clinic. I accompanied the ENT physicians during clinic visits. I explained
procedures and surgical procedures to the patients. I also maintained custody
of the prescription pad. The clinic was used for OVR(Office of Vocational
Rehabilitation) clearance and Medicaid ENT visits. It was the only ENT
Medicaid in Harrisburg. CPR certified in advance adult/child/infant
Pediatric Medicaid Clinic
My job duties included direct patient interaction and pediatrician interaction. I
was the Managed Care Coordinator. I set up all physician requested testing in
our practice of over 10,000 Medicaid minor patients, ages birth to 21. The
Practice had 4 pediatricians, 2 CRNPs and numerous Hershey Medical Center
interns. I managed patient charts and insurance authorizations. Insurance
authorizations are required for all Medicaid services, ER visits and non-
formulary medication. I was the only Managed Care Coordinator for our
practice. I managed the ROSS formula sample program and I oversaw the
premature infant RSV(respiratory syncytial virus) injection program of Synagis
from MedImmune.
References:
1. Donita Nowak
Defense Logistics Agency
IT Specialist
acqvyp@r.postjobfree.com
2.Christine Andrews, L.P.N
Novitas Solutions
Provider Education Specialist
acqvyp@r.postjobfree.com
3. Shirley Jackson
Fraud Investigator
acqvyp@r.postjobfree.com
Contact this candidate