Referral Specialist Data Entry

KRISTA JOHNSON

***** ********* ***. **********, ** 95827 • 626-***-****• *********@*****.***

HEALTH CARE PROFESSIONAL

Medical Billing, Administrative Support, Corporate Accounting

PROFILE

20 year track record in accounting, servicing clients with complex billing transactions, problem solving, and delivering business solutions. A proven leader, team-builder, skilled in identifying and structuring solutions. Administrative and computer experience.

AREAS OF EXPERTISE

Prime 2.0 and 7.2

Portico

Share Point

Omni

CenPas

Customer Service

TruCare

Analytical

Team Building

Emdeon

Amisys

Document Imaging

EXPERIENCE

Health Net - Centene November 2017-Current

Senior Appeals & Grievance Case Coordinator

Review and process member and provider appeals and grievance within federal, state and organizational regulations.

Gather, analyze and report verbal and written member and provider complaints, grievances and appeals.

Maintain files on individual appeals and grievances.

Prepare response letters for member and provider complaints, grievances and appeals.

Serve as a liaison between departments to resolve member issues i.e. prior authorization, updates, claim processing errors, and provider updates.

Health Net - Centene August 2015-November 2017

Kelly Services started as temporary employee

Referral Specialist

Receives and processes inpatient and outpatient notifications within established policies & procedures guidelines, and turnaround time.

Assist with examination of records, related documents, corresponds with providers and health plan personnel to obtain facts regarding member concerns/complaints.

Receive and process all incoming referrals within established turnaround times and production standards to include all necessary guidelines and information to complete.

Maintain current knowledge of provider network.

Adhere to company policies, procedures, guidelines and directives. Recognizes and enforces company security measures and complies with HIPPA standards.

Create, approve, and modify referrals in accordance with established guidelines.

Demonstrate a comprehensive knowledge of Health Plan Benefits, DOFR, and the various departmental functions

Verify member eligibility by systems inquiry or health plan contact

Generate denial eligibility letters

Answer telephone in a prompt, professional, courteous and helpful manner; screens and directs calls to appropriate staff member/department. Respond to routine requests and completes customer service tickets daily while maintaining an accurate phone call log

Maintains strict confidentiality

River City Staffing November 2014-July 2015

Sutter Health

Medi-Cal Collector

Collections, patient account follow-up and patient account maintenance functions in order to maximize cash flow in accordance with EDS, Medi-cal, CCS and GMC guidelines.

Resource person and liaison regarding questions relating to hospital bills, insurance and patient balances.

Research, analysis, monitoring of expected reimbursement, accounting transactions to ensure accurate and compliant reimbursement is collected for services.

MedComm Billing April 2014-August 2014

Hand and Micro Surgery

Billing Analyst

Enter patient demographics and insurance information.

Post charges.

Match CPT-to-ICD Codes.

Submit claims in both electronic and paper formats, and resolve issues on claims before they are sent on to insurance carriers.

Enter payments and adjustments in both electronic and manual data entry formats.

Confirm the allowed amounts match the contracted amounts for major carriers.

Prepare and submit patient statements, and send at least 3 statements to each patient with open balances, and manage all patient A/R questions by phone or by mail for each of our physician clients.

Manage and transfer accounts to collections agency according to each client’s collections/ bad debt guidelines.

Close and balance activities on a daily, monthly and year end basis.

Ohio Presbyterian Retirement Services May 2013-March 2014

Accounts Receivable Coordinator

Processes corporate office vendor invoices, generates accounts payable batch reports and provides batches to Director of Accounting for review and approval per OPRS policy and procedure and generates payments within payment terms.

Monitors and approves community batches while adhering to departmental internal control policies.

Works with corporate office department managers regarding questions or concerns on invoices, statements, or payments; obtains proper documentation from applicable personnel before processing accounts payable invoices.

Assists community personnel with processing accounts payable invoices and batches by answering questions and resolving problems applicable.

Abeo Western Divison June 2010- April 2013

Buena Vista Anesthesia Medical Group

Medical Biller and Collector

Calls assigned payor for payment on accounts over 90 days.

Requests supporting documentation, copies of insurance cards, and other required information.

Performs manual processing reimbursement claims; verifies authorization to bill and send claims to the proper insurance companies.

Preparation of necessary paperwork on refunds or credit balance for processing.

Follows up and appeals all claims denials through the process and determine action needs to be taken.

Answers questions pertaining to rules / regulations of various insurance companies.

Involved with the billing, secondary insurance, collections and the aging report.

Investigates delinquent account holders.

Supplies supervisor / manager with current account status for collections evaluation.

Communicates problems and concerns with supervisor / manager which may lead to inaccurate or untimely completion of reimbursement processing.

Knowledge of MediCal, Medicare, HMO, PPO, Managed Care and other insurance rules and regulations regarding the type of coverage being billed.

Medical Terminology, ICD9 and HCPC codes.

Ultimate Staffing/ L.A. County April 2008 – April 2009

Community Health Plan

Marketing Representative

Customer service duties including receiving inbound calls and referring patients to appropriate medical centers, processing transfers and grievances, and general office duties i.e. document preparation, company mass mailers, and data base management.

Interview plan members to obtain identifying information, financial and other eligibility requirements, and provide application assistance for enrollment into Los Angeles County programs.

Assist customers with understanding of benefit allowances and coverage details.

Liaison between providers and customer regarding co-payments, deductibles, and overall cost.

Initiate member transfer request to new facilities and doctors.

Release Medi-cal holds.

Verizon Services February 2001 – Sept. 2007 Sr. Accounts Payable Accountant

Supervised and trained newly hired employees

Provided detailed accounts payable reports for upper management.

Initiated meetings with accounting controller to streamline payables process and create more efficient methods of payment.

Audit and process invoices prior to vendor payment.

Troubleshoot and resolve purchase order and non-purchase order related issues in regards to vendor invoices.

EDUCATION

2015 - 2020

Ashford University

Bachelor of Arts, Major: Health Care Administration Minor: Psychology

2009 - 2010

Everest College Alhambra, CA

Diploma, Medical Insurance Billing

Everest College-Assertive AR Solutions

Extern/Medical Insurance Biller and Collector

Billed for collection agency approximately 30/day in low volume office.

Applied, adjusted and wrote off payments to patient accounts.

Verified accuracy of patient accounts.

Confirmed patient and insurance information.

Billed workers compensation using CPT and ICD-9 codes.

Made collection calls for workers compensation claims.

1997 - 1999

Sawyer College Sacramento, CA

Diploma, Computer Information Systems

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