Reimbursement Specialist Medical Billing
Resume:
Burnatta Catherine Payne
(Email) *********@*****.***
(Brentwood, CA 94513)
Summary:
Burnatta is an experienced professional with background in analysis and approval of routine and complex claims working with all types of insurance with proven research and problem
Experience with Electronic Health Record and Case Management. Management of Behavioral Health, Medical, or Workers Comp and, LOA claims extensive demonstrated competency in Coding, Medical Terminology, and extensive knowledge with DOFR Program, logical thinking
Managed Care experience in (Medicaid and Medi-Cal), COSMOS, CIWRS or CPW, ICD-9, ICD-10, experience, and coding.
Responsible for performing credentialing delegation oversight compliance for Delegated groups for Medicare, HMO or PPO.
Experienced in identify the needs of customers issues, and provide solutions
Experienced in Preauthorization, claims verification, Insurance, Medical claims and Utilization
Manages high volume of complex data that requires a high volume of accurate data entries and reconciliation.
Extensive Data Entry
Performed different tasks to ensure HEDIS data and reports are accurate, including investigation, auditing, and improvement opportunities.Experienced in customer service to all incoming/ outgoing callers and answer their inquiries.
Proficient in MS Office including Word, Excel, Power point and Outlook.
Available anytime for an interview with 24 hours prior notice and can join immediately.
Skills:
Health Care
Hedis
Customer Care
Grievance and Appeals Coordinator
Member issues
Impatient
Outpatient
Ms office - Excel, MS word, outlook, Pivot table
Policy enforcement
Utilization
Credential
Medical billing
Insurance
Medicare
Medical
Claims
Performance management
Client retention
Document management
Business planning
Education:
Bachelor of Arts Degree in Business /Minor in Medical Management,
Northwestern University Evanston, Illinois (Graduated) Minor Social Services
Work Experience:
Alameda Alliance - Alameda CA 03/01/21 - 01-22-2022
Grievance and Appeals Coordinator:
Coordinate grievance and appeal activities by receiving, handling, and resolving member issues and operational issues with other organizational staff; Perform ongoing data entry.
Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
Make decisions within department guidelines and policies.
Maintain a pertinent documents, case files, and correspondence in an organized, confidential, and secure manner.
Maintain databases for tracking and reporting purposes; and
Complete other duties and special projects as assigned.
Brown &Toland, (Contract), Oakland, CA 05/2018 - 04/15/21
The Inpatient Coordinator
Works in collaboration and continuous partnership with chronically ill or “high-risk” patients and their family/caregiver(s), clinic/hospital/specialty providers and staff, and community resources in a team approach. A typical day is spent on follow-up with patients, family/caregiver(s), providers, and community resources via secure email, phone calls, text messages, and other communications, assisting your assigned nurses with any request providing Home Health and DME (durable medical equipment) authorizations also to assist Families and hospitals to find the correct SNF (skill nursing facilities) and arrange transportation for the member.
Facilitate patient access to appropriate medical and specialty providers Educate patient and family/caregiver(s) about relevant community resources Facilitate and attend meetings between patient, family/caregiver(s), care team, payers, and community resources, as needed Cultivate and support primary care and specialty provider co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.
Promote timely access to appropriate care, increase utilization of preventative care Reduce emergency room utilization and hospital readmission. Increase comprehension through culturally and linguistically appropriate education. Create and promote adherence to a care plan, developed in coordination with the patient, primary care provider, and family/caregiver(s) Increase continuity of care by managing relationships with tertiary care providers, transitions-in-care, and referrals. Increase patients’ ability for self-management and shared decision-making. Provide medication reconciliation.
Connect patients to relevant community resources, with the goal of enhancing patient health and well-being, increasing patient satisfaction, and reducing health care costs.
Hills Physician (Contract), San Ramon, CA 12/2017 - 4/2018
Compliance Sr. Appeals Case Analyst
Primary responsibility to review, evaluates, and corrects Member's grievance letters.
Proven editing experience with cutting and pasting and correcting written content to customers.
100% of the primary function of this role is business writing expertise in a member service,
Grievance and appeal environment all phases of Medicare.
Participated in the review of member letters to provide recommendations and guidance on strengthening letter content and readability for our written correspondence
Process experience in evaluating content and documenting process improvement opportunities improve the quality of letter content and readability, empathetic responses
Participate in managing the organization's complaint and grievance process.
Accountable for investigation of all issues, including collection and documentation of appropriate data. To have a professional representation in customer service role model in interactions with internal and external customers; patients, families, visitors, hospital/health system personnel, outside vendors, external organizations, and physicians.
Identify and address specialty, flagged cases and follow appropriate processes for different types of cases Communicate with a diverse set of internal and external clientele to achieve excellent results in the areas of complaint and grievance handling, compliance, documentation, and enhancement of the member experience.
Research, resolve and communicate complaints and grievances filed by members and communicate Health Plan's decisions appropriately back to member or their authorized representatives.
Responsible for instituting corrective action for non-compliance.
Responsible for performing credentialing delegation oversight compliance for Delegated groups for Medicare, HMO or PPO.
Ensure that complaints and grievances are processed in accordance with regulations, Compliance standards and policies and procedures.
United Behavioral Healthcare Group (FTE), San Francisco, CA 03/1992 - 11/2017
Clinical Senior Appeals Specialist/ Reimbursement Specialist
Analyze and approval of routine claims.
Adjudicating customers claims, completing audits, and adjusting claim examiners' settlement limits.
Processing Urgent Appeals writing letters and notifying facilities of the outcome and advising of further appeal rights.
Process Non-Coverage Determinations and attaching appropriate state and federal rights.
Read/ reviewed 15-20 appeals letters on daily basis as per the compliance/regulations.
Reviewing settled insurance claims to determine that payments and settlements have been
Made in accordance with legal compliance and company practices and procedures.
Reviewing covered losses, establishing proof of loss, over-payments, underpayments and other irregularities.
Using some judgment to determine course of action.
Generate claims to Medicare, Medical and or commercial insurance.
Generate claims related to inpatient or outpatient mental health services.
Accurate recordings of charges, payments and adjustments.
Ensures accurate and timely posting of billing information and posts cash receipts
Performs collections follow-up process in accordance with established procedures
Manages high volume of complex data that requires a high volume of accurate data entries and reconciliation.
Authorizations/denials, naming & housing of imaged documents); Documents claim transactions and activities in claim management system notes and establishes claim diaries for ongoing claim management.
Contact this candidate