Claims Management Quality Assurance

PROFILE SUMMARY

Experienced Healthcare Management Professional with comprehensive knowledge of claims management and billing processes presently seeking a position to utilize my knowledge, skills, and abilities effectively.

SKILLS

Healthcare Administration Benefits Administration Quality Assurance Regulatory Compliance Billing

Collections Claims Management Data Management Process Improvement Research Analysis Documentation Records Management Workflow Management Customer Service Insurance Services

Training Healthcare Management Software Palmetto Waystar MEDITECH Microsoft Office

CORE COMPETENCIES

10+ years of healthcare management experience and significant knowledge of regulatory, reimbursement, claims management, and billing processes.

Contribute positively to operational procedures resulting in process improvement, streamlined workflow, quality standards, and enhanced business operations.

Excellent team player with exceptional communication, conflict resolution, negotiation, and interpersonal skills.

Perform cross-functional tasks to support various areas of operations ensuring high-level productivity and quality performance.

Work successfully with diverse groups and maintain effective business relationships with team members, management, and external entities.

PROFESSIONAL EXPERIENCE

Centra Health Hospital, Lynchburg, Virginia

Senior Appeals and Denial Coordinator, 05/2022 – Present

Perform healthcare administration processes ensuring quality standards and excellent service delivery for multiple payers and regions ensuring best practices.

Manage claims procedures including claims review, appeals, claims adjudication, and research analysis maintaining cost-effective processes to maximize revenue.

Analyze plan documents and claim files to determine the complexity of appeals and develop and implement processes to utilize during the appeal review process.

Coordinate medical testing with outside vendors as well as collaborate with clients and insurance companies to obtain pertinent information and specialized services associated with appeal reviews.

Determine root cause analysis for rejected and denied claims and conduct routine account reviews to provide appropriate resolution.

Research payer remittance advice, determine claim status changes, navigate patient encounters, manage patient information, and resubmit corrected claims to ensure accurate and timely adjudication.

Initiate follow-up as required, review explanation of benefits (EOB), and communicate with team members, leadership, and payers regarding denied claims.

Responsible daily billing Medicare, Medicare Managed Care and Medicaid claims and the appropriate follow-up.

Responding to all inquiries from Medicare, Medicare Managed and Coordination/ explanation of benefits and payments.

Investigating and resolving all outstanding and credit balances on the accounts receivable.

Follow-up all Commercials, Third Party and Workers Compensation Claims

180 Behavior Health Partners, Franklin, Tennessee

Appeals Coordinator, 10/2020 – 04/2022

Managed clinical appeals processes adhering to regulatory requirements ensuring timely written and verbal communication regarding appeals and grievance processes.

Processed clinical appeals consistent with benefit administration guidelines and clinical policies as well as comprehensively reviewed and evaluated appeal requests.

Determined eligibility, benefits, and prior activity related to the claims, payment, or service and managed patient data adhering to HIPAA requirements.

Maintained continuous productivity to achieve organizational goals and effectively resolved billing issues and patient concerns.

Negotiated with insurance companies to resolve issues and enhance business operations resulting in positive outcomes.

Entered physician charges, managed billing, invoice, and collections processes, posted payments, performed month-end reconciliation, and generated reports.

Apricity Resources, LLC, Nashville Tennessee

Reimbursement Claims Specialist, 04/2019 – 10/2020

Managed healthcare management processes including claims management, reimbursement, and collections.

Performed error analysis for disputed/denied claims and provided recommendations for process improvement.

Corrected errors to process claim resubmissions and analyzed daily denial reports to identify trends and create opportunities to improve internal workflows.

Reviewed patient data, analyzed explanation of benefits (EOBs), prepared billing statements, submitted electronic and paper claims, and collected medical payments.

EDUCATION

Tennessee State University, Nashville, Tennessee

Bachelor’s Degree (Criminal Justice), 1999

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