Kenneth Proctor

**** **** ****** ** · Lancaster, CA 93534

adxoep@r.postjobfree.com · 818-***-****

Highly Accomplished Reimbursement Specialist & Medical Biller

Qualification Highlights

•Over 25 years of successful experience in Reimbursement, Customer Service, Appeals, and Billing and Coding.

•Expertise in patient access, insurance reimbursement, and buy and bill.

•Knowledgeable in a variety of medical coding, pharmaceuticals, devices, and buy & bill products.

•Experience negotiating contracts for managing Prior Authorizations and Patient Appeals.

•Adept at resolving insurance denials, problem-solving reimbursement barriers, and ensuring patient access.

•SME on local and national payor coverage including Medi-Cal, Medicare, Commercial, CalPERS, and Medicaid.

•Exceptional leadership, communication, negotiation, decision-making, and relationship-building skills.

•Results-driven, self-motivated, disciplined, strategic, proactive, accountable, and decisive problem solver.

Key Competencies

Reimbursement

Market Access

Account Management

HUB Services

Insurance Denials/Appeals

Third-Party Billing

HCPCS/ICD-10 Coding

Reimbursement Pathways

Patient Access

Patient Assistance Programs

Prior Authorizations

J-Codes

AWP/WAC/HOPPS

Durable Medical Equipment

Government Payors

Commercial Payors

Medicare Contracts

Medicare Part A, B, C, D

Specialty Pharmacy

RBM Relations

Customer Service

Buy and Bill

Pharmaceuticals

Radiopharmaceuticals

NCCN/ASCO Guidelines

Fee Schedules

Claims/Claim Adjudication

Professional Experience

Apria Healthcare · Indianapolis, IN

Branch Support Specialist-Remote (November 2021 – Present)

Answer incoming patient and referral source calls related to new orders, and ongoing patient service needs, troubleshooting, order status, and other general inquiries.

Complete outbound calls to patients and referral sources regarding order receipt confirmation, documentation requirements, insurance benefits, patient scheduling, order status, and patient Wellness calls.

Review incoming fax orders and determine the action to be taken.

Collaborate with back-office qualification teams to facilitate the timely processing of orders.

Partner with the Sales team to obtain complete and accurate documentation based on the payor and other regulatory requirements.

Collect payment and billing information as needed.

Assist with coordination of patient Positive Airway Pressure (PAP) classes.

Centene/Health Net · Rancho Cordova, CA

Claims Analyst I-Remote Temp (December 2019 – November 2021)

Processed facility and professional claims, in inpatient, outpatient, and ambulatory settings.

Accurately reviewed all incoming facility (UB92) and professional (CMS-1500) claim forms.

Reviewed authorization status codes and notes affecting the adjudication of the claim.

Matched authorizations to claims and maintained current desk procedural and reference materials.

Reviewed appeals and complaints; researched any missing or required information.

Utilized documented team processes to ensure compliance with departmental standards.

Analyzed trends in claims processing issues, assisted with identifying and quantifying issues and reviewed the work process.

Ran claims reports regularly through provider information systems.

Facilitated exchanges of information between the grievance, claims processing, and provider relations systems.

Kenneth Proctor

HeliNet/Robert Half · Van Nuys, CA

Medical Billing Assistant-Temp (July 2019 – August 2019)

Developed and submitted professional claims to private insurance carriers, Medi-Cal, and Medicare by electronic and hard copy billing.

Scrubbed claims from the clearinghouse for resubmission and accuracy.

Prepared, reviewed, and transmitted claims using billing software, including electronic and paper claim processing.

Reviewed and resubmitted denied and rejected insurance claims.

Ensured all claims submitted to government and private payers comply with applicable federal and state regulations.

Placed calls to insurance carriers regarding any discrepancy in payments if necessary. Identify and bill secondary or tertiary insurance.

Researched and appealed denied claims.

Answered multiple phone lines, and corrected coding when necessary.

Secured important medical documentation required by the insurance plan.

Followed up with health plan on outstanding claims within standard billing cycle timeframe.

Worked closely with hospitals, clearinghouses, and insurance claims adjusters.

Maintained patient confidentiality, followed HIPAA guidelines, and preserved data confidentiality.

PA Medical Center/Dr. Grell · Compton, CA

Medical Biller/Office Clerk (December 2017 – December 2019)

Managed and updated patient records. Greeted patients, and scheduled appointments.

Processed insurance claims for private and employer insurance reimbursement, and filed provider appeals to insurance for payment or underpayment. Handled patient accounts.

Submitted reimbursement requests to Medicare and Medicaid.

Maintained billing software by updating rate change, cash, spreadsheets, and current collection reports.

Verified patient insurance eligibility and benefit verification for treatments, hospitalization, and procedures.

Entered patient demographics into the database. Extensive data entry.

Checked each insurance payment for accuracy and compliance with contract discounts.

Set up patient payment plans and worked on collection accounts.

Requested any missing patient information.

Reviewed and submitted referrals and authorizations.

Followed all regulations and guidelines set by Medicare, state programs, and HMO/PPO.

Responded to questions and complaints from patients or insurance companies.

Filed and maintained organized documentation of all billing and record.

USC Keck · Los Angeles, CA · Medical Biller/Medical Billing Collector (July 2015 – December 2017)

Anthem Blue Cross · Woodland Hills, CA · Network Management Rep (December 2014 - July 2015)

Beverly Hills Cancer Center · Beverly Hills, CA · Externship Biller/Coder (May 2014 – July 2014)

PGRX · Atlanta, GA · Senior Claims Examiner (August 2007 – December 2011)

Meridian Healthcare · Woodland Hills, CA · Reimbursement Specialist (January 2002 – July 2007)

UHP Healthcare · Inglewood, CA · Snr. Customer Service Rep (February 1993 – December 2001)

Education

UEI College · Encino, CA

Medical Billing and Coding Certificate (Graduated June 2014)

Thomas Jefferson High School · Los Angeles, CA

Diploma (Graduated)

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