Medicare Billing and or Collections

KWANA HILTON

Clearlake, TX ***** 832-***-**** *********@*****.***

Medicare billing and collections on In Patient Out Patient, PSYCH, SNF, and RHEB claims process Following, AHA ICD-10- CM/PCS and AMA CPT-4 coding conventions, UHDDS and CMS guidelines and régulations. Utilize the 3M Encoder to verify coding APR-DRG.

CORE COMPETENCIES

Medicare Claims Processing Medical Billing & Collections Explanation of Benefits (EOB) Review Claims Adjudication Denial Management ICD-10, CPT, HCPCS Coding Eligibility Verification Insurance Billing Revenue Cycle Management Insurance Follow-Up Direct Data Entry (DDE) SSI Claims Processing Electronic Medical Records (EMR) Systems HIPAA Compliance Microsoft Word and Excel EDUCATION & CERTIFICATION

Diploma in Medical Assistance Medicare Boot Camp 2018 Ahima Member for study CCS Certification 2020

CLINICAL EXPERIENCE

Medicare Claims Specialist UHC Optum – Remote Apr 2022 – Present

Medicare Part A and B claims collections, focusing on accurate resolution of denied and rejected claims.

Knowledge of UB-04 Facility claims in patient Part A & B and, Facility Self Denials process and overlapping date-of-service rules.

Correct claims edits for Correct Coding Initiative (CCI) edits and Medically Unlikely Edits (MUEs)

Utilize Medicare systems such as DDE, for claim status, and payments and rejections, and payer-specific rules.

Confirm Medicare eligibility for primary, secondary, or tertiary and Medicare open workers comp, COB process.

Monitor trends in claim denials. DDE RTP’s implement corrective measures, to improve denial rates and reduce A/R days. Office Assistant Bealine Environmental Services – Pasadena, TX Sep 2019 – Mar 2021

Maintained hazardous waste manifests through system for EPA compliance, supporting reporting of regulated materials.

Responded to incoming calls and emails from clients and regulatory agencies, providing documentation support and clarifying submission requirements for environnemental records.

Assisted with filing, organizing, and retrieving compliance documents to ensure smooth audits and inspections. Medicare Part A & B Claims Rep Houston Methodist Hospital – Katy, TX May 2016 – Nov 2018

Corrected Medicare Part A and B claims flagged in claims reports to ensure accuracy and alignment with CMS regulations. Monitor ADR’s and RAC’s and Other Thiard-party processes request.

Followed up with insurance companies to secure payments, resolve denials, and reduce outstanding receivables.

Complete Medicare collections for médical necessity dénials in a timely manor.

Research and investigate NCD/LCD denials for Reopening and Reconsidération process. Medical Claims Specialist Houston Physicians Hospital – Webster, TX Feb 2014 – Apr 2016

Verified accuracy and completeness of incoming provider claims, ensuring proper claim submission.

Recovered over $500K in revenue by proactively addressing claim discrepancies and resubmitting pending claims.

Monitor ADR’s and RAC, s and other third-party process.

Colobrate with other departments, obtaining and updating claims information for process. ADDITIONAL PROFESSIONAL EXPERIENCE

Medicare Specialist St. Joseph Hospital, Houston, TX, Sep 2008 – Jun 2014 Medicare Claims Analyst HCA-Atlanta Medicare Service Center – 2004-2008 Reference upon Request.

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