Payment Specialist Data Analyst
Resume:
Venese Malone
Atlanta, GA 30350
To whom this may concern after reviewing all the jobs that fit my job profile, I’m leaving a small profile for what you’re looking for in the healthcare industry.
You Need: My Experience:
o3-5 years of EDI processing More than 10 years of EDI processing
o3-5 years medical claims More than 30 years of medical claims
o3-5 years workman comp claims More than 10 years of workman comp claims
o3-5 years of medical billing software More than 15 years of medical billing software
o3-5 years posting payment for vendors More than 15 years of refund payment
o3-5 years patient collection Knowledge of HIPAA
oMicrosoft Office experience Microsoft Office experience
oKnowledge of HIPAA Web Access
oAppeal Letters Professional phone etiquette
oWebb Access Knowledge of Appeal Guidelines
oKnowledge of Appeals Guidelines Appeal Letters
I trust that my background experience and qualifications will be of interest to you. I hope that we will have the opportunity to discuss my qualifications in more details, so that I can assist your organization in achieving it’ business goals. I may be reached at 470-***-**** and ********@*****.***. I look forward to hearing from you soon.
Sincerely,
Venese Malone
3205 Summer Lake Drive
VENESE MALONE
Home: 470-***-****
Atlanta, GA 30350
********@*****.***
Cell: 470-***-****
SKILLS AND TRAINING
Epic
Microsoft Office Word
Emdeon Clearinghouse
Microsoft Office Excel
Centricity System
Microsoft Outlook
EnThrive
Diamond 6000/9000
ICD-9/CPT and HCPCS
Quick Books
Gateway Clearinghouse
FTP Applications
Athena
IDX-GPMS
Mozilla Firefox (file handling skills)
Epremis
I-suite
Star
Trac Tool
PROFESSIONAL EXPERIENCE
CorroHealth Hendersonville, TN 01/22 – Present
Patient Account Specialist
Examines denied and in process claims to determine reason for resolution, communicates directly with payers to follow up on outstanding claims, file technical appeals, resolve balance variances, and ensure timely reimbursement.
Ability to identify with specific reason denials, and cause of payment delay.
Works with management to identify, trend, and address root causes of issues in the A/R.
Maintains a thorough understanding of federal and state regulations, as well as payer specific requirements and taken appropriate action accordingly.
Documents activity accurately including contact names, addresses, phone numbers, and other pertinent information.
Demonstrates initiative and resourcefulness by making recommendations and communicating trends and issues to management.
Needs to be a strong problem solver and critical thinker to resolve accounts.
Ensemble Health Partners Cincinnati, OH 11/18 – Present
Revenue Recovery Specialist
Resolve underpaid claims from Commercial, Medicare, and Medicaid insurances
Validate denial reasons and ensures coding is accurate and reflects the denial reasons.
Contact and modify the process of the payer changes when making the necessary recovery process
Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations.
Follow specific payer guidelines for appeals submission
Research contract terms/interpretation and compile necessary supporting documentation for appeals and work payer projects as directed.
Perform research and makes determination of corrective actions and takes appropriate steps to code and route account appropriately.
Escalate denial or payment variance trends to NIC leadership team for payor escalation.
Conifer Health Solutions Marietta, GA 02/18 – 11/18
Senior Denials Auditor
Validate denial reasons and ensures coding is accurate and reflects the denial reasons.
Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary
Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations.
Follow specific payer guidelines for appeals submission
Research contract terms/interpretation and compile necessary supporting documentation for appeals and work payer projects as directed.
Perform research and makes determination of corrective actions and takes appropriate steps to code and route account appropriately.
Escalate denial or payment variance trends to NIC leadership team for payor escalation.
Pediatric Service of America Atlanta, GA 08/17 – 02/18
Medicaid/Commercial Manage Care Specialist
Responsible for insurance billing and accounts follow-up.
Maintains status in billing daily downloads as well as completing referrals and returned claims within the required timeframe.
Resolving denied claims, working appeals and review contracts to ensure accurate payment of claims
Strategically solve routine problems and inquiries on individual accounts. Verifying benefits.
Manage daily reports to include AR reports and Aging reports/Electronically bill Commercial and Medicaid claims
Piedmont Healthcare Atlanta, GA 06/12 – 08/17 Denial Contract Analyst
Resolve underpaid claims from Commercial, Medicare, and Medicaid insurances
Analyze the provider reimbursement by the contracts submitted by the Health Plan
Post adjustments and credit adjustments
Contact and modify the process of the payer changes when making the necessary recovery process
Articulate contract provisions and state or federal legislation to insurance representatives
Respond to claim denials from insurance companies to ensure contractual payment of submitted claims
Maintain updated information for the payer’s contracts, state/national guidelines and contract management systems as appropriate for each contract
Resubmit claims and write appeals on denied claims to insurance companies
Maintain persistent and professional follow-up over the phone to ensure claims are resolved
Follow standard policies and procedures that are updated quarterly
Anesthesia Healthcare Partners Marietta, GA 01/11 - 04/12
Cash Applications Specialist (Company closed)
Responsible for posting and balancing daily lockbox deposit from SunTrust Bank, Regions Bank, Bank of America, and First Tennessee Bank daily
Deposit batches for different data sets (entities)
Post and balance daily EFT deposits utilizing ERA/manual application for Government and Non-Government payers
Identify day to day ERA issues/rejected data on ERA reports, able to maintain daily cash posting/reconciliation schedules, and unapplied schedules
Daily cash balancing sheets and able to assist with special projects for upper management when needed
Apollo MD and Payments MD Atlanta, GA 07/09 - 12/10
Billing EDI Rejection Specialist
Responsible for retrieving rejected EDI claims from Gateway Clearinghouse on emergency room and radiology
Processing of complex workman comp and medical commercial EDI claims, with prior authorization request
Adjust research, inquires of explanations of benefit, correspondence, investigate denials
Respond to any request for further EDI claim information and contact insurance company if an incorrect payment is received on a EDI claim or a denied EDI claim
Identify and report denial trends effecting all UB-04 and CMS-1500 payments on old appealed claims
Collecting reimbursement with an appeal letters on Emergency room and Radiology claims
Amerigroup of TN Memphis, TN 03/00 - 04/09
EDI Data Analyst Team Lead 09/03-04/09
Managed and maintained the automation process for EDI claim processing for approximately 8 associates which included EDI Claim Processors and EDI Eligibility Representative by determined training needs within the department
Internal audits, claims code review, and claims EDI processing knowledge, and business rules build
Increased provider and customer satisfaction using business analysis tools, Quality improvement measurements, and Compliance
Assisted single and multiple doctor practices and billing services transition from paper based and/or other billing software systems
Developed EDI standards and improved EDI submission rate from 5% to 87% with 75% of the process automated
Maintained provider contract database to ensure accurate claim payment
Investigated/resolved medical claim issues on contractual provider contracts
Managed and maintain the HIPPA compliance 835
Maintain excel spreadsheet to track and analyze weekly and monthly productivity electronically to distribute to Director or Manager
EDI Data Analyst 02/03-09/03
Responsible for performing test on various program logic to update diamond system with accurate medical processing
Processing of professional and institutional medical claims according to departmental policies and procedures
Meet and exceed departmental Audit standards of 87% accuracy
Familiar with applicable medical definitions, reason codes, ICD-9, HCPCS, and general ledger codes to effectively evaluate accurate claim adjudication
Review manuals, contracts and other reference manuals.
Process Electronic Data Interchange claims daily
Claims Adjudicator 03/00 - 02/03
Process professional and institutional claims according to Departmental policies and procedures
Meet and exceed departmental Audit standards of 97% accuracy
United American of TN Memphis, TN 10/94 - 03/00
Claims Payment Specialist
Responsible for negotiating all UB-92 and HCFA-1500 payments on old appeal claims
Respond to requests for further claim information and contact insurance companies if incorrect payment is received on a claim or denied
Identify and report denial trends effecting all UB-92 and HCFA-1500 payments
Posting payments, recouping overpayments, refunding overpayments, duplicate payments and reimbursing providers
Communicate daily with providers and members regarding any discrepancies on processed claims
EDUCATION
Fairley High School University of Phoenix
08/81 - 05/84 01/12 – 06/17
Certificate: Diploma Certificate: Bachelor’s degree
Major: Accounting and Mathematics of Science in Healthcare Administration
Contact this candidate