firstname.lastname@example.org • 346-***-**** • Spring, TX 77373
REVENUE CYCLE SPECIALIST
Knowledgeable, tenacious revenue cycle specialist with a decade of proven experience working with government and non-government claims, delivering effective billing results impactful in optimizing reimbursements.
— Areas of Expertise —
Efficient Claims Collections Managed Care Insurance Terminology Clean Claims Electronic Billing CMS Guidelines CPT/ICD10, HCP Coding Medicare Clearinghouse Systems Medicaid Web Portal (Texas) UB04/CMS 1500 Claim Form Requirements DDE Error Resolution
— Career Accomplishments —
Identified government payer underpayment of 140 claims due to error in use of the CMS Fee Schedule guidelines. Resubmitting accounts resulted in increased payer reimbursement for the hospital, and increasing A/R collections for the company.
Contributed to increased clean claim rates by identifying an opportunity for billing improvement. Achieved a solution for Return to Provider claims based on incorrect providers information. Researched rejection reason codes and updated NPI’s to resolve claims errors that reprocessed for payment. Error-free future processing enhanced the A/R (accounts receivable).
PRIOR WORK EXPERIENCE
MEDNAX-MedData Houston, TX
VA Project Revenue Cycle Claims 7/2016 — 5/2019
Review charges to resolve edits, errors, coding denials, and issues with billing daily prior to submission to insurance carriers. Ensure proper payment posting and contractual adjustments. Confirm payment dates by calls to insurer. Upload HIM documentation for adjudication needs, use EOB for root cause of rejection reasons; call insurer (and use web portal) to question why a claim was rejected, and prepare appeals, notating actions and resolution steps. Maintain knowledge of commercial and managed care Insurance Terminology.
Effectively maintain work queue-volume by knowing where to research errors, who to contact for follow-up, why rejections occurred, how to correct and resubmit, and what time-lines apply from initial billing, follow-up, and deadlines for appeals. Resolve problems with CPT/ICD10, HCPCS, NPI and diagnosis, per CMS guidelines, and resubmit claims in Epic billing system for timely filing. Mentor teammates. Analyze trends and perform appropriate tasks of resolving concerns.
Reduced aged receivables by 74% in the first six months of special project assignment in 2018 from $6.2 million to $1.6 million with continual A/R collection trends in the following year.
Outperformed daily productivity of 25 hospital accounts billed by 52% on average by relentless queue organization with detail-oriented sorting to work complex records first, billing EDI in a fast-paced manner to increase cash and reduce outstanding accounts receivables aging.
Traveled independently up to 30% of the time for claims adjudication on-site of complex, high dollar claims, reinforcing client satisfaction, also directly addressing insurers about claims not yet processed.
Known for dedicating focus to propose and ensure resolution in billing issues of complex claims.
Ray-Dawn Joseph • Page 2
Government Employees Insurance Company Katy, TX
Licensed Adjuster, Third Party Liability Claims Examiner 5/2015 — 7/2016
Average 75 claim accounts and 100 outbound calls daily, compliant with insurance regulations.
Acknowledged by clients for exceptional standards of service, securing consistent customer satisfaction.
Used strong interpersonal skills to negotiate payment arrangements with third party collection agencies and clients.
Bariatric Surgical Center - NeWeigh Houston, TX Clinical Appeals Associate 4/2004 — 6/2008
Integrate insurance experience to effectively appeal medical necessity claim denials for a diverse range of insurers including Medicare, Medicaid, commercial and self-insured plans. Understand insurance carrier payer processing protocols. Knowledge of when to escalate items. Research coding references for ICD9, CPT/HCPCS and diagnosis codes with modifiers information accuracy on payer claims. Efficiently locate denial reasons from EOB and remittance advice to prepare and timely submit appeal according to operation processes for payer sources. Record all information of actions taken on accounts, precisely according to provided templates.
Skilled medical necessity appeal writer credited for 94% appeal success rate performance.
Consistently met and exceeded challenging A/R appeals goals, surpassing expectation goals by 69% in the first year and 70% in subsequent years.
Insurance Claims Specialist, AIG, Houston, TX (1/2013 — 5/2015)
Primary responsibility to verify benefits, eligibility information accuracy, and coverage.
Established as primary accounts reporter tasked with performing reconciliations in Microsoft Excel.
Workers’ Compensation Claims Examiner, Pasadena Community Health, Houston, TX (2/2011 — 1/2012)
Evaluate and assess patient claim cases, complete templates, coordinate referrals and prepare hearings.
Consultant, Gerson Lehrman Group, Houston, TX (6/2008 — 2/2011)
EDUCATION AND CREDENTIALS
Advanced Medical Degree
Harvard — Boston, MA
Bachelor of Science in Biology & Naval Engineering
San Diego State University — San Diego, CA
— Technical Proficiencies —
Microsoft Office Outlook MS Excel MS Word Epic Billing Cerner Solutions Medicaid Web Portals eClinical Solutions Meditech Healthland (Centrix) NexGen Emdeon Eclinical Works HealthSmart Paragon Optum Availity DDE Gateway EDI SSI Ability Citrix CPSI Optum nThrive
— Professional Development & Affiliations —
Military Veteran — US Naval Officer Epic Superuser Training
HIPAA Guidelines and Regulations Compliance Training with Certification Claims Resolution Training
Coaching & Mentoring Workshop Anti-Harassment Training Workplace Diversity Training