Quality Assurance High School
Resume:
Appeals Denial Analyst proficient in interpreting complex
insurance policies and leveraging in-depth knowledge of regulatory compliance to overturn unjustified denials. Proven track record of improving appeal success rates and enhancing revenue recovery. Demonstrated ability prioritizing workflow applying key HIPAA and CMS guidelines. Critical thinker who activates strong analytical skills to investigate trends in large amounts of data and formulate conclusions based on findings. Excels at Identifying and resolving incongruencies with the highest sense of urgency.
PROFILE
CONTACT
NAME
PHONE
ADDRESS
**********@*****.***
Carrollton, TX 75006
Kissa Baker
SKILLS
JUNE /2016
Associate Of Science:
Accounting
North Hennepin Community College Minneapolis, MN
EDUCATION
JUNE /1993
High School Diploma:
AIC High School
Minnesota
11/2022 - Current
EnableComp - Appeals Denial Analyst
O Gather and retrieve assigned cases from queue reviewing CPT codes & EOBs compared to insurer contracts. Validate if reimbursement is required. If so, submit an appeal letter attaching the necessary medical documentation to the support appeal submission.
O Complete necessary documentation and correctly enter data in the appropriate system applications, templates, and communication process. O Utilize in-depth knowledge of healthcare billing issues, claims, and other plan benefit information.
O Maintained detailed records of all appeal activities, ensuring transparency and facilitating quick retrieval of information during audits. 11/2017 - 11/2021
Arise - Quality Assurance Analyst
O Monitored customer conversations for quality assurance purposes, ensuring that policies and standards were followed.
O Evaluated customer interactions for compliance with company standards and regulations.
11/2014 - 02/2018
First Choice Emergency Room - Revenue Cycle Specialist O Interfaced via telephone and email with insurance payers/vendors such as Anthem Blue Cross Blue Shield, UHG, UMR, CIGNA, and Aetna, to bring accounts current with suitable repayment plans.
O Identified discrepancies, verified patients' eligibility, and reached out to nurses and third-party payer billing staff to get corrected coding and modifiers on the claims. 05/2016 - 12/2017
McKesson - Accounts Receivable Analyst
O Monitored monthly activities and managed vendor invoicing to prepare appropriate financial reports.
O Obtained and investigated information from sales, trade promotions, and customer service departments to verify account discrepancies. 06/2010 - 08/2014
Allina Health - Accounts Receivable Specialist
O Systematically computed accurate data collection, and financial information using EPIC EHR system.
O Utilized knowledge and understanding of hospital revenue cycle operations for registration, charge capture, health information management, and payment posting. EXPERIENCE
10+ years of experience in healthcare and PBM industry Associates degree in Accounting
7 years of Billing issue resolution
Knowledgeable of Affordable Care Act and Healthcare Reform (HCR/ACA)
Medicare Appeals
CMS and HIPAA Compliance
Appeal Investigation
Regulation Compliance Management
Process Implementation Support
Correspondence Analysis
Medical Assistance
Ability to multi-task and meet multiple competing deadlines Proficient in Microsoft Office Products (Outlook, Word, and Excel)
KISSA BAKER
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