Holly A Muggleston

** ***** ****

West Townsend Ma

978-***-****

adumco@r.postjobfree.com

Objective

Continuing to expand my knowledge in the medical revenue cycle management industry; and social development awareness, in a diverse community. To maintain my personal goals and achieve new goals in these industries. I feel a position inside the organization, relevant to my experience, will also benefit the expansion of your business and assist in maintaining a profitable revenue cycle and your social service ideology. Objectively I would like to continue to maintain professional relationships in the industry as I persevere. My years of experience will speak to your success.

Professional Profile

Work Experience

OptionCare Enterprises, Inc.

246 Boston Turnpike

Shrewsbury Ma 01545

Formerly known as Walgreen’s Infusion Respiratory Services/ Critical Care Systems

(Early 2008- to 2017).

Current employer information upon request. 2017-current

Under Option Care management prior to Walgreens, I created insurance claims for Express Scripts, Accredo and Medco.

Medical billing and coding

Utilizing the Health Care Procedural Coding System (HCPCS) unit calculation to properly code on a HCFA for the service(s) and/or drug(s) administered, that is allowed for reimbursement.

Utilizing (MCR /DME) Coding A,B,E,G,J,K,L,S coding; with Pump coding ruling applied. Not limited to this list.

Reviewing ICD-9 and currently ICD-10 codes while creating ins claim based upon qualifying diagnoses.

Reviewing claims for appropriate information that supports a clean claim prior to submission to the appropriate payer: correct authorization for per diems (supplies) and drugs and specific therapies, allowable/list amounts, correct codes and modifiers if required by payer, and ensure all supporting documentation is attached or on file.

Review dosing and frequency and route of administration against the corresponding prescription.

Review contracts and fee schedules to determine allowed amts.

Review measurements, (volumes, grams, package sizes) in correlation with payers that require specific breakdowns and formulas to determine pmt.

Submit claims via third-party EDI system; Emdeon, Zirmed, Payer website Portals or on paper HCFA

Review rejections in various E-Systems for claims that require specific actions for resubmission for pmt.

Run System reports to review all status of claims

Split Claims for Drugs and Supplies if payer requires,

Intake verification eligibility

Use payer websites/calls to insurance companies to verify pt eligibility; date spans for eligibility and coverage options

Review for Primary; secondary and tertiary coverage and RX Plans supported by a PBM. (Pharmacy Benefit Manager) including any MVA or Work Comp.

To submit documentation that supports any authorization request

To check the status of authorizations regularly and resubmit when needed for current coverage

Medical collections

Navigate reports in Excel to determine patient priority: high dollar, aging, credit and debit balances, etc.

Review Explanation of Benefits/Remits and audit responses if further collections activity is necessary: resubmission, appeal, corrected claims, write off, revenue pick up, refund and escheatment (overpayments), etc.

File appropriate appeals, corrected claims and related collective actions within timely filing according to payer guidelines for payment

Navigate provider portals for appeal and claim information

Identify issues and trends with claims and report to supervisor or reimbursement managers.

Perform necessary adjustment in the pt A/R with approval of designee.

Submit claims to secondary payer if pt is MCR/MCD for secondary allowable

Able to communicate with insurance companies representatives verbally professionally and effectively to ensure pmt or claim status. Speak with providers/ doctors/hospitals/nursing facilities etc regularly. Able to network professionally.

Cash Posting

Review EOB’s for patient information and appropriately select corresponding invoice to post the pmt.

Identify ‘true’ pt responsibility and transfer to the coinsurance or patient for pmt.

Help to identify unapplied cash to post to invoices

Identify issues and report if large dollar balances are left after the payment to the designee.

System Experience

NDC Billing Software; using Billing Information Numbers, Processor Control Number following National Council for Prescription Drug Programs, guidelines for adjudication.

Reviewing claim adjudication Internal Control Numbers to ensure correct payment

Other payer portal billing systems iEmhsys, RXHome, Daytech, Brightree.

Experience in Excel, Word, Note,Powerpoint able to learn as directed.

Abundant experience with third-party systems including: Zirmed, Emdeon, MMIS and other provider websites

Can easily navigate provider portals and electronic systems to locate information or provider inquiry lines

Extensive experience in PBM NDC systems; Daytech-Claims Engine 2000 for Part D drug billing

Utilize Paint for clean copying of documentation for attachments or to share via internal communication e-system following all HIPPA guidelines.

Extensive experience using Outlook as an internal method of communication and directive

Sisco and other methods of secure email applications.

Webinar ease of access.

Internal FAX, Copy and Scanning equipment.

COMPLIANCE

I am in Compliance with the Health Insurance Portability and Accountability Act of 1996. I continue to follow these laws as directed state and federal guidelines to the best of my knowledge following guidelines provided to me. I continue to stay compliant with Fire Safety training at the work place. I also continue to keep current on all infective and blood borne pathogen safety guidelines that are offered and mandatory by each employer.

Payer Experience

Medicare with Medicaid

MCO ( managed care organizations)

Extensive experience with:

Mass Medicaid : ACO/ MCO/C3

MASS HEALTH WAIVER PROGRAMS/ABI/FRAIL ETC

DME

Vermont Medicaid

Maine Care

Network Health

Tufts Medicare Preferred and Senior Options

Tufts Commercial

Tufts Public Health Plan ( formerly Network Health)

Boston Medical Center

Neighborhood Health Plan/Always HP

Senior Whole Health

Commonwealth Care Alliance

TPL billing

Multiple Part D

Blue Cross –Ma and various states.

Integra and various partners

United HC

Harvard Pilgring/tufts

Ease of learning any HP and its contracted guidelines.

Specialty Areas for medical billing

Enteral Coding

Total Parenteral Nutrition ( TPN)

ABX ( antibiotic )

Chemotherapy and corresponding dates and drugs

Immunoglobulin (igg or ivig) coding and authorization billing processes for Part D and Mass Health specifics

Hydration

Cath Care

DME Billing Wheelchairs/beds/mobility/bathroom etc.

Port Care

Education

High School

Groton Dunstable High School

Groton Ma

Diploma 1986

Fitchburg State University

Pearl Street Fitchburg, MA

Bachelor of Science with Honors ; May 2014

Interdisciplinary Studies

Combing Psychology, Biology and Criminal Science

Middlesex Community College

Bedford/Lowell Mass

Aug 2007

Associate in Science

With special interest in Criminal Science and Liberal Arts

Mount Wachusett Community College

Ft Devens Mass

1988

Required courses for employment purposes

With special interest in education

References

References are available on request.

Contact this candidate