Insurance Health
Resume:
Carol L. Parker
Missouri City, TX 77489
Phone: 281-***-**** HM
832-***-**** Mobile
Email: *********@*****.***
QUALIFICATIONS
Experienced Claims Examiner.
Twelve plus years in the healthcare reimbursement field.
Strong research and analytical skills.
EDUCATION
2015 Medical Coding Certification Training, Career Step Online
2005 Medical Transcription Training, Career Step Online
1997 Medical Billing and Administrative Certificate, Northwest Business School
1994- Texas Southern University, Houston, TX
1996
EMPLOYMENT
2015-2016
Reimbursement Specialist, Intrafusion
Responsibilities include working with online Electronic Health Records system to bill various insurance providers/clearing houses and Medicaid, ensure the online Electronic Health Records system is setup, updated, and maintained in accordance with insurance provider's billing demands, posting charges, payments, and adjustments, review and process EOB, create efficient method to track claims submitted, paid, denied, and outstanding invoices, work with insurance providers to resolve denied claims, manage authorization requests and insurance verification ' HMO, PPO, Medicare, etc.
2014-2015
SME, ITManna
SME (Subject Matter Expert) for WTCHP (World Trade Center Health Program) for CSC. Duties include: Creating test scenarios for 3M's product for OPPS (Hospital Outpatient Prospective Payment System)/APC pricing, developing test scenarios that the pricer needs to do, training/educating staff on the inner workings of the OPPS, evaluating and testing outcomes to makes sure they align with OPPS expected result.
2013-2014
Facility Claims Analyst, Kelsey Care Advantage – Medicare (Payer Side)
Responsible for the adjudication of complex facility claims for provider reimbursement. Duties include: converting complex facility claims to EPIC, ensuring correct pricing for 200 facility claims per day implementing, Release of Information, Hospital Coding, HIM Deficiency Tracking 3M's product for OPPS (Hospital Outpatient Prospective Payment System) and Ambulatory Payment Classification (APC). Duties also include developing and testing multiple scenarios to ensure correct fee schedules and pricing information generated accurate reimbursement. Essential job functions include: Performance of DRG pricing methods, Outpatient Prospective Payment System mechanics (OPPS) and Contractual Payment Rates.
2012-2013
Medicaid/Medicare Billing Specialist, Independence Heights FQHC
Reviewed patient documentation to abstract clinical data information and assess appropriate level and assign the appropriate codes for procedures prior to exporting to claim. Submitted claims to Medicaid, Medicare, and Commercial insurance for reimbursement. Reviewed EOBs and followed up on denials and underpayments.
2007-2012
Sr. Claims Examiner, Community Health Choice – Medicaid (Payer Side)
Researched and reviewed hospital, specialty and non-specialty Medicaid, CHIP and CHIP Peri-natal claims to ensure they were adjudicated in accordance with provider contracts and member's appropriate plan of benefits; also responsible for the adjudication of complex facility claims for provider reimbursement. Duties include ensuring correct pricing for 200 facility claims per day implementing 3M's product for OPPS (Hospital Outpatient Prospective Payment System) and Ambulatory Payment Classification (APC). Duties also include developing and testing multiple facilities to ensure correct fee schedules and pricing information generated accurate reimbursement. Essential job functions include: Performance of DRG pricing methods, Outpatient Prospective Payment System mechanics (OPPS) and Contractual Payment Rates. Also Monitoring work queues, works on errors - overall support of HIM modules.
2003-2007
Clinical Billing Specialist, Mariner Health Care, LTAC, Nursing Home
Responsibilities included completing benefit verification; sequencing of payers, Duties included manipulating data and building reports for the purpose of analyzing them to ensure the most effective billing processes were implemented. Duties also included maintaining the Clinical Billing database by entering and sequencing payer sources, and preparing and submitting HCFA and UB92 claims electronically to various HMOs, Medicare, and Medicaid. Duties also included assisting in generation and reconciliation of room and board charges, some ancillary charges related to specific payers (Medicaid Surplus, Rest Home), posting cash for Private, Insurance, Managed Care, Hospice and VA accounts, and back up posting of cash for Medicare and Medicaid receipts.
1999- 2003
Claims Examiner, First Health
Duties were to process paper claims via scanned images using the ACT electronic claims processing application. Also to process electronic claims via work queues, including complex HCFA 1500s and UB92s in accordance with company and client policies and procedures. Exceeded the company production goal of processing 27 claims per hour, and quality goal of 98% accuracy.
1997-1999
Customer Relations, Primeco
Duties were to take incoming calls in a call center environment from customers regarding billing processes and new accounts.
SKILLS
10 plus years expert experience with the following products:
3M's product for OPPS (Hospital Outpatient Prospective Payment System)
Ambulatory Payment Classification (APC)
3M’s Coding and Reimbursement System
EPIC, Tapestry
FACETS
Centers for Medicare and Medicaid Services (CMS)
Encoder Pro
Gtess Claims Processing and Management Software
Word, Excel, Outlook
Windows OS
Experience developing test scenarios that the OPPS needs to do
Experience evaluating and testing outcomes to makes sure they align with OPPS expected results
Experience training/educating staff on the inner workings of the OPPS
4 years expert experience
The candidate would be less technical and highly functional about Provider Reimbursement.
13 years expert experience
Contact this candidate