Specialist Iii Data Entry
Resume:
TYLISHA JOHNSON
CMRS, CBCS, RPHT, CMAA
Dallas, Tx ****************@*****.***
EXPERIENCE
AR RECOVERY ANALYST & DENIAL SPECIALIST III
August 2023- Present
Health plex Operations
Healthcare billing and collections
Specializing in Medicaid accounts
Generate sales leads/ assist member with open enrollment questions Identify and assess member’s needs to achieve satisfaction Proficient in Medicaid/ Medicare billing and regulations Strong analytical and problem-solving skills
Excellent communication and negotiation abilities
Experience with electronic health record (EHR) systems Knowledge of healthcare compliance and reimbursement processes/ submit appeals to Medicaid/Medicare Payors Ability to work collaboratively with cross functional teams Proficient in Microsoft Excel and billing software Build sustainable relationships and trust with member’s accounts through open and interactive communication. Listening to member’s concerns and handling complaints and returns. Give detailed explanations of services or products. Review member accounts and transactions while resolving issues. Review, research, analyze and process complex healthcare claims by navigating multiple computer systems and platforms and accurately capturing the data/information for processing Ensure that the proper benefits are applied to each claim by using the appropriate tools, processes and procedures Complete data entry for all daily documentation and communicate the status of claims adhering to reporting requirements.
Experience in UBO4 reimbursement and pricing
Communicate through correspondence with members and providers regarding claim payment or required information using clear, simple language to ensure understanding. Learn and leverage new systems and training resources to help apply claims processes/procedures appropriately. Software Systems Experience:
EMR
Oracle Cerner,
CPSI,
Meditech, eClinicalWorks,
NextGen, Allscripts,
Greenway Health,
EHR
Practice Fusion
CUSTOMER SERVICE REPRESENTATIVE III DSNP NAVIGATION, DALLAS, TEXAS United Healthcare Group
SEPTEMBER 2022-AUG 2023
· Verifies patient specific benefits and precisely documents specifics for various payer plans including patient coverage, cost share, and access/provider options according to Program specific SOPs
· Verification process could include electronic validation of pharmacy coverage and medical eligibility
· Identifies any restrictions and details on how to expedite patient access
· Could include documenting and initiating prior authorization process, claims appeals
· Completes quality review of work as part of finalizing product
· Reports any reimbursement trends/delays to supervisor MEDICAL AR FOLLOW-UP & DENIAL
SPECIALIST III, FRISCO, TX
Conifer Health Solutions, February 2019-June 2022
Proactively identified and solved complex
problems impacting operations management and
business direction.
Provided outstanding service to new and long-
standing customers by attending closely to
concerns and developing solutions
Delivered an exceptional level of service to each
customer by listening to concerns and answering
questions.
Consulted with customers to determine best
methods to resolve service and billing issues.
Greeted customers to facilitate services,
determine service needs and accurately input
orders into electronic systems.
Documented conversations with customers to
track requests, problems, and solutions.
Completed documentation for all actions and
customer interactions.
Performed full research to check claims and
viable solutions to individual issues.
Reviewed accounts with aging balances and
contacted customers to review options.
Negotiated dispute resolution and
communicated resolution status to customers.
VERIFICATIONS SPECIALIST II, Frisco, TX
Amerisource Bergan Benefits, July 2018-November 2018 Collects and reviews all patient insurance information needed to complete the benefit verification process. Verifies patient specific benefits and precisely
documents specifics for various payer plans including patient.
coverage, cost share, and access/provider options
according to Program specific SOPs
Verification process could include electronic validation of pharmacy coverage and medical eligibility.
Identifies any restrictions and details on how to
expedite patient access.
Could include documenting and initiating prior
authorization process, claims appeals.
Completes quality review of work as part of finalizing product.
Reports any reimbursement trends/delays to
supervisor.
Reviews denied claims to ensure coding was
appropriate and make corrections as needed.
Ensures billing and coding are correct prior to
sending appeals or reconsiderations to payers.
Investigate claims with no payer response to
ensure claim were received by payer.
Strong understanding of payer websites and
appeal process by all payers including commercial
and government payers including VA, Tricare,
Medicare, Medicaid, and Medicare Advantage
plans
Promote the CCPSA culture of team
collaboration, while identifying and
implementing opportunities to enhance the
shared values of the group.
Exhibit exceptional customer service skills;
answering patient and insurance calls;
prompt return and follow up to all
interactions; prompt response to requests
for information, both internally and
externally.
Initiative-taking resolution of issues and
timely response to questions and concerns.
Clearly document issues and resolution.
Deliver timely required reports to the
management team; initiates and
communicates the resolution of issues, such
as payor denial trends due to coding and
billing errors.
Wrought follow up work queues.
Responsible for identifying missing
payments, overpayments, and analyzing
credits on accounts.
Ability to successfully track and follow up
on information requests.
Work with group to facilitate information
and resolve charge questions.
Other duties as assigned.
Reviews and finds trends or patterns of denials to prevent errors.
Assists and confers with coder and billing
manager concerning any coding problems.
Strong research and analytical skills. Must be a
critical thinker.
Stays current with compliance and changing
regulatory guideline.
Demonstrates knowledge of coding and medical
terminology to effectively know if claim denied
appropriately and if appeal is warranted.
Supports and participates in process and quality
improvement initiatives.
Achieve goals set forth by supervisor regarding
error-free work, transactions, processes, and
compliance requirements.
Software systems Experience
EPIC
Paragon,
Zirmed
(EMR) electronic medical record
(EHR)electronic health record
EDUCATION
Diploma in Pharmacy Technician St. Louis College of Health Careers - Fenton, MO May 2016 to February 2017 Medical Billing Administrative Specialist Missouri College - Brentwood, MO May 2015 Certified Medical Reimbursement Specialist – Brentwood, MO May 2016 High school diploma Riverview Gardens High School- May 2009 SKILLS
Medical Billing Insurance Verification Managed Care Typing ICD-10 HCPCS EDI Windows Accounting
Communication Skills Teaching
Medical Coding CPT Coding Epic Employee Orientation Patient Care
Electronic Medical Records, Medisoft Clinical Laboratory Procedures: Physical Examinations
Enjoys The Challenge of New Projects and Managing
Multiple Projects Simultaneously
Analysis And Critical Thinking Skills Medical
Administrative Procedures:
Highly Organized Able to Multi-Task and Accomplish Multiple Objectives
Scheduling, Filing, Keyboarding, Multi-Line Telephone Health Care Communications
Billing, Collection Techniques Medical Insurance
Strong Communication and Relationship Building Skills Processing, OSHA/HIPAA Regulations, Medical
Terminology, Computer Operations
Documentation Review Customer Support, Technical
Support, Microsoft Access
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