Medical Billing Resolution Specialist

Professional Summery

Many years of experience in Commercial Insurance and Medicare Managed Care collections, account management, appeals, grievances, and recovery services in the healthcare field. Experienced with diverse Medical Groups and various health care settings

Skills

Experienced in medical billing practices (billing, collections, postings, adjustments, and balancing)

Proficient in medical terminology, ICD-10/9, CPT, HCPCS

Proficiency using the Microsoft Office suite of products, billing systems, and provider systems.

Excellent customer services

Proficient documentation, research, problem solving, and strategically analysis.

Knowledge of medical insurance contracts.

Strong knowledge of payer issues

Knowledge of legal risk and regulatory/statutory guidelines HIPPA, privacy, Affordable Health Care Act, etc.

Education

American Career College

Certificate in Health Insurance Examiner & Medical Billing

Work Experience

Tokio Marine HCC

Claims Client Representative/CCR (WFH) 03/2021- Current

Access in-house resources including Actuarial, Underwriting and Marketing departments to assist in determining and attaining business goals.

Understand and interpret a variety of employer plans of health coverage and excess insurance policy.

Communicate in writing and verbally with Third Party Administrators/TPA client as needed.

Participate in implementation calls between internal and external clients.

Provide documentation for ACH processing to broker/client. Work with internal staff to ensure setup is timely and accurate.

Travel with the Regional Marketing Representative for building and maintaining client relationships.

Senior Specific Auditor (Santa Ana, CA) 12/2018 - 03/2021

Reviewing claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination.

Responsible for customer service, and the financial risk associated with an assigned block of Stop Loss claims.

• Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim

The ability to apply the appropriate contractual provisions (both from the underlying plan of the policyholder as well as the TMHCC contract) especially with regard to eligibility and exclusions.

Maintain claim block and meet departmental metrics

Establish cooperative and productive relationships with professional resources

Prepare written rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records

OPTUM

Senior Recovery Resolution Specialist (Murrieta, CA) 02/2016 - 11/2018

Handles information about patient services and how those services are paid by investigating and pursuing recoveries through contact with various parties; works with providers to recover overpayments.

Provide claims expertise support by reviewing, researching, investigating, negotiating, and resolving all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities.

Analyze, identify trends, and provide reports as necessary.

Communicate directly with the provider to analyze and identify the provider’s service issue that caused credit balances.

Initiating telephone calls to payers, providers and other insurance companies to gather coordination of benefits data. Investigate and pursue recoveries.

Process recovery on claims. Ensure adherence to state and federal compliance policies, reimbursement policies and contract compliance; conduct contestable investigations to review medical history and monitor large claims including transplant cases.

Perform administrative duties, logging refund requests, invoicing claims for check run and submit to provider AP offices, track retraction requests, prepared monthly goal projection for the provider, weekly updates on CBO paids, used pivot table to create Team report on suspended claims and other duties as assigned.

Case Installation Specialist (Santa Ana, CA) 09/2015 - 02/2016

Performed peer audit on Health Plan products built by other co-workers

Thoroughly analyze benefits on SOB, make sure the benefit rules applied matched. Benefit Plans, Benefit attributes, and accumulators.

Audited Group files and benefit plan updates against source documentation.

Responsible for ensuring data integrity within the system as it relates to Groups and benefit plan updates. Report all findings and advised builder to correct errors made. Input all products information on the Product Log.

Checked accuracy and quality of products to maintain a 98.50% as a passing score for the Team. Prepared audit sheet for each product reviewed.

Finalized the audit and assigned to QA and make revision on the product if requested by QA. Built new health plan products (HMO, PPO, POS, and HDHC) based on SOB and Companion grid received using Facets system.

Make sure everything match before building the product; applied the benefit rule to the appropriate benefits (Ambulance, ER, IP, Intermediate Care, Psychological Testing, OP, Autism and etc..) reviewed deductible for any roll over and limit amounts. Once the product is completely built, assigned for peer audit and then to QA.

Discussed any discrepancy found on SOB with administrators so the issue can be related to the Group or client. Attend Team meeting online periodically for current updates and changes. Maintain quality in building and auditing of products. Perform other job functions as assigned.

UCI Medical Center

Account Specialist (Orange, CA) 11/2005 - 06/2015

Analyzing, auditing, research, problem solving, editing and reviewing high dollar claims inventory daily make sure they are been billed and paid on a timely manner.

Coordinate with other internal departments to ensure proper payments.

Performed patient accounting functions including posting and reconciliation. Effectively interprets and applies financial policies and guidelines related to assigned patient accounting functions.

Reviewed explanation of benefits, coordination of benefits and remittance advices from insurances; resolved account balances by disputing/appealing for underpaid amount. Write off balances when payments received and posted on accounts.

Replied to insurance requests; interact with internal and external departments; prepared aged accounts to vendors/agencies for further collection and managed the cash flow on accounts.

Meet month end deadline and goal; work special projects and perform other duties as assigned.

Completed necessary processes to insure payments of claims was processed and documented correctly by providing any additional information or adjustments needed.

Processed appeals to insurance when appropriate.

References available upon request.

Contact this candidate