Talisa Torres

347-***-****

ad14mj@r.postjobfree.com

Precise efficient certified medical billing professional with over 9 years of experience in inpatient and outpatient claims. From reconciling insurance to resolve accounts to understanding insurance contracts, provider and patient appeals. Additional experience in utilization management from creating authorizations to verifying codes and units are properly authorized before sending to patient and provider. Expertise in auditing clinical documentation in the utmost confidentiality. Along with years of deep understanding with data security, patient privacy and regulatory compliance within the healthcare sector.

CORE QUALIFICATIONS

Medical Writer Knowledge of HMOS, LOBs, Medicare and Medicaid Accounts/Claims Reconciliation Insurance Contracts, Appeals and EOBs Completed comprehension HIPAA training Knowledge in EPACES Strong Communication Skills Vendor and Provider Relations EDUCATION AND CERTIFICATIONS

Stratford Career Institute

New York, New York

• Certification in Physical Therapy Assistant

02/2024

Manhattan Institute

New York, New York

• Certification in Medical Billing and Coding

03/2017

City of New York Department of City Administrative Services New York, New York, New York

• Certification in Clerical Associate

01/2015

PROFFESSIONAL EXPERIENCE

Clinical Correspondence Writer/Editor 04/2021 to Present Healthfirst Inc.

• Performs daily reviews of letters produced from TruCare to member and providers to ensure adherence to Article 44 and 49 of the NY State Public Health Law and Appendix F, Medicare Managed Care Manual Chapter 13 and commercial contracts and others as necessary.

• Conduct daily audits of member and provider correspondence to ensure compliance with all State and Federal regulations.

• Participates in the corporate-wide letter management improvement program and function as one of the department's participants in writing/editing member and provider letters for the Care Management and Utilization Management departments.

• Collaborate with Care Managers in UM, CM, the leadership team and peer reviewers to comply with regulatory-mandated notices. Appeals and Grievances Specialist 01/2020 to 04/2021 Healthfirst Inc.

• Responsible for case development and resolution of cases, such as grievances, pre- service appeals and post service appeals while utilizing appropriate source of information, including eligibility, claims authorization service forms, faxes, and mail.

• Collaborate with provider doctors, social workers, and community-based providers to coordinate resolutions.

• Document all encounters with providers, members, and vendors; follows up as needed and update cases based on resolutions. Claims Adjuster 01/2015 to 12/2019

MetroPlus Health Plan for Health and Hospital Corp

• Respond to all claim inquiries from provider sites personnel including physicians, clinical staff, and site administrators.

• Act as a key liaison and service representative for all provider phone/faxed inquiries and problem resolutions.

• Research provider appeals regarding pricing discrepancies and claim denials.

• Perform claim adjustments to correct erroneous payments (overpayments/underpayments) SUMMARY

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