Medical Insurance

Natalie M. Pilkinton

***** ********** **** **** * Lakes Fl 34639

813-***-**** ***********@*****.***

Objective:

Seeking a challenging, rewarding position with a stable, growth-oriented company.

Experience:

Surgery Partners – 10/31/2017-01/07/2020

Clinical Appeal Specialist

● Submit detailed, customized appeals to payers based on review of medical records and/or operative reports in accordance with Medicare, Medicaid, and third-party commercial insurers guidelines

● Assist other staff members in identifying denials based on technical, billing errors or lack of information on claim forms as opposed to denials related to frequency of procedures performed and/or the payers specifications as to what their policy deems medically necessary

● Review other staff members documentation and reconsideration requests prior to submitting to the payer to ensure proper reimbursement and to overturn the denial on the first attempt

● Meet with management weekly to discuss patterns from our staff or insurers that would cause denials in payment or denials in our request to have our claim reprocessed for payment

● Assist with training staff members to recognize and resolve claims that were denied in error on the payers’ end and how to effectively communicate this to the payer via telephone or written request

● Ensuring the accounts receivable ratio turnover is maximizing the company’s effectiveness to collect receivables that are due to the company for services rendered

BioSpine Institute, LLC – 01/2017-06/2017

Billing Manager/Claims Coordinator

● Responsible for leading 20+ staff members regarding our EMR Software, Viatrack Clearinghouse & Billing/Coding questions

● Assist in implementing the day-to-day functions of the Billing department for Professional and Facility accounts receivable, payment posting, patient billing concierge, LOP Analysts & the Benefit/Authorization team

● Delegate various functions and special projects to appropriate staff

● Communicate with the Legal Department regarding any patient accounts that have Legal representation – Personal Injury Protection

● Upload all in-office procedures and outpatient surgery Operative Reports to our Coding Vendor

● Audit Coding to ensure that when returned to key the LCD, NCD, NCCI is appropriate for the payers’ specific guidelines and ensure that we are following AMA/CPT coding guidelines

● Directly over seeing the A/R Specialists and implementing worklogs within our EPM for more efficient follow up on outstanding balances to streamline the billing process

● Worked in the BBP to update various functions to ensure the system was following Best Practices to report to Administration/Upper-Management and CMS

● Implement Written Policies and Procedures to ensure timely reimbursement and payment posting from insurance & patient payments for services rendered

●Personnel development; staff meetings

Florida Orthopaedic Institute – 09/2016-01/2017

Reimbursement Specialist

● Ensure timely collections of accounts receivable in the Central Business Office for outpatient & inpatient physician claims. Provides adequate follow up on each claim to ensure it was paid at the maximum reimbursement based on our contract/fee schedule with the insurance carrier

● Submit supporting medical documentation to insurance payers in a timely matter as requested. Reviews office notes and operative reports to verify we billed the correct procedure code(s), ICD-10 diagnosis code(s) & modifiers set forth by CMS, AMA, CPT guidelines & utilizes AAOS (American Academy of Orthopaedic Surgeons) reference books to avoid denials common in Orthopaedic billing and coding

● Communicate with management on insurance denial trends or Payer specific guidelines. ●Obtain retro-authorizations and/or referrals not obtained prior to the patients’ procedure causing claim denials. If unable to obtain a retro authorization or referral, a formal appeal or reconsideration letter is sent to the insurance carrier along with supporting documentation to request that the claim be reprocessed based on medical necessity.

●Submit requests to our physicians for addendums needed to process claims and coding changes.

Sets up Peer to Peer appointments with the insurance carrier with our physician’s approval and availability.

AMSURG Central Billing Office - 05/2016-07/2016

Medical Accounts Receivable Specialist

● Follows up on claims & open balances to determine any front-end rejections through the clearing house, denials from the payer or payment and adjustment posting issues.

● Send appeals and medical records to show services were medically necessary; to justify our billing of CPT codes or for payer claim auditing purposes.

● Monitors claim denial trends to keep claims from going over 60+ days in insurance aging reports. ● Completing month end reports to ensure financial benchmarks are met of 49%/18%.

● Responsible for transferring balance to the correct payer and/or patient.

Professional Medical Services, LLC - 07/2014-10/2015

Claim Representative II

● Analyze accounts to determine the correct claim status and/or action needed for resolution.

● Follow up with insurance companies to have clean claims reprocessed via the telephone or online portals.

● Send appeals and/or medical records as needed.

● Contact patients if & when their insurance carrier is requesting that information be updated on the patients end as a courtesy

● Recognizes denial trends and utilize all resources to get the claims either corrected and resubmitted or dealing with insurance liaisons’ to have reprocessed in bulk if they deny in error on the payers’ end.

● Responsible for notating claim status and actions towards resolution in the Health Information System/ Electronic Medical Record Program

● Becomes familiar with each insurance carriers’ payer specific guidelines for accurate billing and claim corrections

● Verify all coding is correct and all the CPT / ICD-9 guidelines are being followed.

USMD Hospital– North Richland Hills, TX - 03/2013-07/2014

Patient Access Representative

● Responsible for entering and auditing all in office charges and hospital charges prior to being submitted to the insurance carrier, posting payments & maintaining all payment plans for the clinic

● Meeting with physicians to discuss CPT and ICD-9 changes based on documentation for proper reimbursement based on payer specifics

● Verifying benefits and eligibility, pre-certifying and obtaining referrals for procedures and/or referring patients to specialists, counseling patients on the cost and setting up payment plans as needed

● Followed up with the insurance carrier for claims that denied in error

● Experience working the front desk, scheduling appointments, answering the phone lines for 5 physicians. I worked back desk in which I would collect coinsurance balances, schedule follow up appointments and provide any instructions needed for the patients next visit. I trained new staff members and assisting with reports and other tasks for the office manager

● Responsible for abstract coding of all services per the physicians Operative Report for Inpatient and Outpatient consults and surgeries

Spine Team Texas - TX 07/2012- 03/2013

Patient Financial Services

● Responsible for obtaining medical benefit information and up to date deductible and out of pocket maximums & eligibility from private insurance companies and Medicare via phone or web portals

● Coordinating with patients, appointment schedulers, front desk & insurance companies to confirm all the patients’ personal information corresponds with all the involved parties to avoid claim denials

● Inputting data correctly into Centricity to ensure that all departments can understand and get needed information

United American Insurance Company- McKinney, TX 10/2007-05/2012

Customer Service Representative

● Verify medical benefits and claim status to medical providers, policyholders, and third parties

● Processes policyholder’s requests from phone calls, written correspondence, and emails

● Ensuring that other internal departments get the information needed to further process applications, claims or any over-payments/refunds

● Worked in a designated department for Employer Group policies as well as individually purchased Health & Life Insurance policies

● Responsible for training new staff members

Education:

●Celina High School - Celina, TX 2007

●University of Texas at Arlington - Arlington, TX 2013

● Fred Pryor – Working with Difficult People

● Fred Pryor – Team Building, Coaching, Leadership Skills for Managers & Supervisors

Certifications:

● Certified Billing and Coding Specialist- #S5BPN4L7

● Certified Medical Administrative Assistant- #D3G3Q5W8

Skills & Software:

● Excellent oral and written communication skills internally and externally; professional email etiquette & responds in a timely matter

● Proficient PC skills, Microsoft – Word, Excel, PowerPoint, Outlook

● NextGen (EPM, EHR, ICS & File Maintenance knowledge), GE-Centricity, Epic, STAR, Nextech, Filemaker, Onbase, Viatrack, Zirmed

● Ability to analyze information and make logical conclusions

● Organizational skills and the ability to multi-task or focus on special projections until completion

● 10-Key proficient (8000+ kph) & WPM 70+

Contact this candidate