Carol L. Parker

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

Missouri City, TX 77489

Phone: 281-***-**** HM

832-***-**** Mobile

Email: acx6b4@r.postjobfree.com

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