Human Resources Revenue Cycle
Resume:
Diane Williams
Oakland, Ca. 94605
**********@*****.***
EXPERTIS
• Account
Receivable
• Acute Care/SNF
• Administration
• Analytic/Problem
Resolutions
• Appeals
• Authorization
Eligibility
• Behavior Health
Billing
• Business Office
Manager
• Charges Posting
• Claims Auditor
• Claims Examiner
• Claims Processor
• Claims Examiner
• Claims Processor
• Collection
• Denial Management
• Financial Intake
Counselor
• HMO, PPO,
Commercial
• Hospital
Billing/Professional
and Clinical
• ICD-10/CPT/HCPCS
Codes
• Health and Life
Insurance License
• Managed M/Cal
• Manager/Supervisor
• Medical Staff
Credentials
• Medical
/Dental/Mental
Billing
• Medicare
Advantage
• Medicare
Supplement
• Payroll
• Provider Relation
• Research/Analysis
• Sales/Life
Insurance
• Skilled
Nursing/Custodial
Care/LTC
• Territory Sales
Manager
• Training &
Development
• Worker
Compensation
PROFESSIONAL PROFILE
City View Post Acute
Business Office Manager
San Francisco, Ca. 08/2024 to present
Responsible for day-to-day operations for City View Post Acute hospital with 180 bed Medicare and Medi-Cal certified skilled nursing facility. Short-term and Long-Term rehabilitation. Payroll and Revenue Cycle Financial. Duties include resident’s medical billings, verify insurance authorization. Post payments from insurance carriers and cash payment residents, prepare collection notices. Strongly work with the prior authorization team to ensure that patients, healthcare providers, and insurance companies navigate the authorization and reimbursement process effectively and timely. Follow-up and appeal. Resolve payment issues. Send out Demand letters. Weekly audits of all accounts. Monitors staff performance to ensure quality to make sure department goals are met. Increase collection of revenue by 30% by sending monthly statement twice a week and collection letters and calling residents to remind them of their payment. Set residents RFMS accounts. Assist those residents who do not have any medical coverage with M/Cal application and those who need to renewal application. Set-up payment plan and credit card payment. Processing payroll, timesheet corrections, entering new employees into system, onboarding, and orientation, assembling and maintaining personnel files, managing unemployment claims, and workers compensation claims. Responsible for carrying out the assigned accordance with current existing federal and state regulations and established company policies and procedures. Process authorizations, benefits verification, pre-registration, communication to providers, payers and patients, appeals, and coordination with. Assists Physician in with interpreting, review payer contracts and guidelines for medical necessities. Informed medical providers of patients’ financial status. To ensure timely notification of any health conditions or diagnosis that could qualify patients for other medical programs that may help them with their healthcare costs. Expedited patient referrals to specialty offices faxed medical records, answered patient and specialty office calls, and completed referral requests. Called insurance companies for patients to obtain benefits and precertification. Manage new hire paperwork. Assist with new hire orientation to go over the payroll and benefit. Responsible for employee vacation and sick hour balances.
Bonita House
Manager Billing Specialist/Credential
Berkeley, Ca 07/2023 to 11/2023
Mental Health billing for non-profit clinic. A Dual Diagnosis Residential Treatment program with 15 bed co-ed facility alone with 10 mental health Crisis sites. Billed for treat both psychiatric and substance use disorders. Throughout the Alameda County PSP system; Oakland, Berkeley, Albany, Pleasanton, and San Leandro. Medi-Cal and Medicare eligibility tracking system and maintain work units reports and records suitable for county, state, and federal auditing. Directly supervise employees. Responsibilities include interviewing, hiring, and training employees, planning, assigned and direct work; apprising performance, rewarding and discipline employees; addressing complaints and resolved problems. Develop a new protocol for all billers. Prepares monthly invoice/demands for County mental health contracts and maintains all necessary source department. Partner and communicates regularly with the Finance department to accurately prepare program demands. Plans and directs patient insurance documentation, workload coding, billing and collections, and data processing to ensure accurate billing and efficient account collection. Analyze billing and claims for accuracy and completeness; submit claims to proper insurance entities and follow up on any issues. Follow up on claims using various systems, i.e. practice management and clearinghouse. Reduce account receivable by improving accuracy of claims and reduce claims denials. Collaborate with the work unit to ensure that all necessary service documentation is complete within the relevant timelines and accounted for in charts.
The Davis Street Community Center
Clinic Fiscal Manager 07/2022 to 03/2023
San Leandro, Ca
Davis Street Community Center is FQCH HRSA Health Center Program to provide primary care services in underserved areas. A community-based and patient-directed organizations that provide affordable, accessible, high-quality primary health care services to individuals and families. Oversaw clinic quality and medical patient care. Collaborate with the CMO and the clinic team to ensure that the required primary care services are assessable to patients. Provide direct and indirect patient care in-person, by phone and electronic communication devices. Providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. As the Clinic Fiscal Director of Revenue Cycle Management reports to the CFO was responsible for overseeing and coordinating all revenue cycle activities, for the Medical, Dental and Behavioral Health Clinic with a goal of maximizing reimbursement in a cost-effective manner that is compliance with federal, state and payer-specific billing requirements. Assist in the preparation and coordination of audits (i.e., HRSA, D.H.S./Managed Care, CHDP, Health Plans, CPSP, etc.) as necessary. Oversaw the overall policies, objectives, and initiatives of our healthcare facilities’ revenue cycle activities to optimize the patient financial interaction along the care continuum. Develop systems of patient-centered and integrated care that respond to the unique needs of diverse medically underserved areas and populations. Directly supervises the scheduling, admitting/registration, and patient financial services supervisors. Thorough knowledge of patient financial services (PFS) processes and standards related to billing, collections, and cash posting. General knowledge of patient registration, finance, and data processing. Exceptional understanding of medical practice management, with thorough knowledge of CPT and ICD-9 and ICD-10 billing and diagnosis codes. Work directly with healthcare providers, payers, and patients to resolve issues related to prior authorization. Collaborate with Billing, Collection, and Patient Access Managers to plan, organize, and deliver regular staff meetings for the department. Collected 180 days and older medical claims and patient cash accounts. Review patient account for maximize reimbursement with minimize financial risk and increase A/R net revenue by reducing bad debt from write-off; and reducing denials and increasing collection. Reduced the average days of A/R from 79 to 45 in a three-month time period. Increased net collection from 65% to 90%. Collected over $3.6 million in unmanageable debt in three months. Exceeded department cash receipts goals by 35%. Audit claims to resolve payment issues and exceeded financial accuracy of 99.8%. Surpassed goal by averaging (33% above quota) and exceeding the 76.3% departmental goal. Transunion
Revenue Cycle Rep III Lead/Trainer 03/2019 to 03/2021 Fremont, Ca.
Third-Party outsource company billing medical claims, dental and behavior health for hospital throughout the United States, such as John Muir, San Francisco, Community Hospital of Monterey, Zuckerberg San Francisco General Hospital, Texas Oncology, and New York, Responsible for billing and follow-up on medical claims, denials, and appeals. Run report, assigned staff work, weekly audit, and staff performance. Prepared and analyses accounts receivable reports, weekly and monthly financial reports, insurance contract, and collection comply with accurate statistical reports. 80% revenue increase with 90% denial rate went down and 15% accounts receivable reduce. Strong knowledge of Medicare, Medi-Caland Commercial insurance. Verify patient demographics, insurance eligibility, and benefits to prevent claim denials and ensure timely reimbursement. Address and resolution of denials, short pay, patient responsibility, payment posting. Accurately captures and enters charges from clinical documentation to ensure correct billing and faster claims processing. Evaluated and redesign departmental workflow and departmental responsibilities. Establish a regularly scheduled revenue cycle meeting to discuss strategies and ensure everyone is educated in the direction of the department. All other projects, goals, issues surrounding the revenue cycle, conflicts, or concerns as directed or indicated by Administration. Follow and monitor compliance with hospital policies and standards. Maintains extensive knowledge of revenue cycle and regulatory requirements associated with governmental, managed care, and commercial payers. Lucille Packard Stanford Children Hospital (contract) Authorization Coordinator
San Francisco, Ca. 06/2018 to 03/2019
An acute care general hospital is an institution whose primary function is to provide service to patients in an acute phase of illness or injury, characterized by a single episode or a short duration, from which the patient returns to his or her normal or previous level of activity. (Cardiologist, neurology, general surgery, hematology and etc.) Call center environment contacting patients to verification their insurance. Getting prior authorization to ensure patients benefit from decreased waiting periods, fewer appointment reschedules, and broader treatment accessibility, resulting in elevated levels of patient satisfaction. Examine patient records to determine if treatments, procedures, or medications require prior authorization, ensuring that each case is assessed accurately according to authorization criteria. Confirms patient insurance details, verifying that the insurance coverage is in place for the proposed healthcare services. Preparing and submitting detailed authorization requests to insurance companies, complete with all necessary documentation, ensuring that insurance claims are processed efficiently. Worked closely with healthcare providers to collect necessary clinical information, streamlining the authorization approval process. Keep track of authorization requests, follow up with insurance companies, and keep detailed records of all communications related to insurance claims. Investigates insurance denials, resubmits requests, and appeals when needed to ensure that patients receive the care they require. Explain the prior authorization process to patients, including any potential delays and financial implications, while always ensuring patient confidentiality. In-depth proficiency in medical terminology and coding using CPT and ICD-10 St Rose Hospital 05/2018 to 06/2018
Revenue Cycle Billing Tech. III (contact)
Hayward, Ca.
An acute care hospital that provides emergency services such as cardiology, emergency, diagnostics etc., 195 beds hospital. Revenue Cycle Management: Coordinated efforts across all departments to decrease billing errors and increased revenue, working closely with billing & collections to determine opportunities for improvement. Medical billing, collection, follow-up, and post payment. Appeals and denial. Responsible for all phases in medical billing; Medicare, Medicaid, HMO’s PPOs, and other Third-Party Payer including secondary claim and COB’s. Medical billing, denial, appeals and authorization. Electronic claims submission. Review claims for error rates.
Alameda Health System 03/2018 to 05/2018
Revenue Cycle Billing Tech. III (contract)
San Leandro, Ca
An acute care hospital that treats severe injuries patients such as stroke, brain, and multiple traumas. They provide inpatient and outpatient services. Along with providing hospital-based Skilled Nursing Facility for long-term care services, 536 bed hospitals. Revenue Cycle- Government and 3
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party hospital and professional billing. Medical billing, collection, post payment, appeals, denial, and follow-up on patient accounts. Ensure claims are entered into and submitted with 24 hours of receipt. Process over seventy-five medical claims a day. Optum Healthcare (United Healthcare) 10/2017 to 03/2018 Authorization/Eligibility (contract)
Concord, Ca.
• Responsible for verifying patient insurance eligibility and coverage and securing third party payer authorization for services to be rendered, for over 10,000 members. Duties include research, analysis, and reconciliation of complex eligibility issues. Research analyzes and reconciles the discrepancies between health plan eligibility tape files and the legacy system according to established department guidelines. Verifies that all enrollments contain the correct group numbers, plan and effective date as reported by the health plan. Timely filing third party payer authorization requests, including ensuring all necessary data elements needed for an authorization (e.g., CPT codes, diagnosis codes). Ensures services scheduled by outside providers have approved authorization as required by payer and procedure prior to service. Communicates with patients, insurers, and other appropriate parties pertaining to insurance verification and authorization. Notifies Hospital Utilization Review and/or Admitting offices of reviews completed for urgent, elective, uninsured/underinsured admissions and outpatient procedures requiring discharge planning after admission to inform the hospital of authorized services, length of stay and outcomes necessary if concurrent review is necessary during the hospital stay. Refers underinsured/uninsured patients and/or point- of-service pre-payment required services to the Pre-Service Patient Financial Responsibility and/or Financial Assistance team(s) to determine if the patient is eligible for assistance and obtain payment prior to services being received, when applicable, to help manage the organization’s bad debt. Follow up on outstanding authorizations to ensure timely decisions and facilitate patient care. Anka Behavioral Health 03/2017 to 10/2017
Medical Billing Supervisor (contract)
Walnut Creek, Ca.
Provides inpatient mental health and dual diagnosis in a long-term residential program. Directly oversaw the daily operation of 10 mental health inpatient hospital and residential medical account receivable. Oversaw the billing department and ensuring the accurate and timely submission of claims. Managed billing processes, address discrepancies, and collaborate with other departments to ensure accurate financial reporting. Trained and supervised billing staff, develop billing policies, and ensure compliance with healthcare regulations. Decreased billing cycle turnaround time by 40% by implementing automation into the process. Improved productivity and decreased backlog by 25% within the first four months. Monitor and manage billing processes and workflows. Get prior authorization of the patient’s enrollment and benefits with mental health insurance. Use ICD codes for behavior and mental health, allowing us to submit smooth claims. Responsible for preparing, assigning, and reconciling. Payment posting and balances batch report. Responsible for auditing claims and claims rejections and the necessary correction. Develop and implement department billing/collection Policies and Procedures are always current.
Centers for Elders Independence(contract)
Claims Processor/Lead Claims Auditors 04/2014 to 03/2016 Acute care, physician groups, home care, hospice, long term care and manage care for seniors. Managed day-to-day operation for a third-party administrator manage and train teams of up to eight claims adjusters at all levels. Work with a large TPA firm doing hospital claims auditors. Oversee all customer complaints, insurance companies, lawyers, and other vendors. Performs assigned audits (collections, denials, focused review, etc.) by researching documentation, analyzing information, and making recommendations to improve flow of claim and apply corrections as needed. Audit claims to resolve payment issues and exceeded financial accuracy of 99.8%. Surpassed goal by averaging (33% above quota) and exceeding the 76.3% departmental goal. Maintained a superior quality rating of 94% in file handling and claims resolution by examine and audit medical claims to make sure claims are submitted correctly for payment. Oversaw quality and quantity of work produced, ensuring employees are held accountable. Maintained a superior quality rating of 94% in file handling and claims resolution by examine and audit medical claims to make sure claims are submitted correctly for payment. Kaiser Permanente (Oakland, Ca.) (contract)
Senior TPL & CMISP Medical Biller 12/2008 to 06/2009 An in-depth experience in all phases of Healthcare Management inpatient/outpatient, hospital, billing, clinics, and physicians billing. Workers Compensation claims examiner. Audit medical record documentation includes chart and operative reports to extract details of procedures performed and verify against daily super bills. Monitors and evaluates the overall department revenue identification, billing, and cash control in terms of ability to meet established targets. Responsible for operations of patient business services, insurance verification and workers compensation. Monitor payer contracts and analyze remittances to ensure obligations are met. Managed the overall TPL department, and collection knowledge of Medicare, Medicaid, CHDP, HMO’s, PPO’S, IPA’ and TPL.
Regional Sales Manager
Life Insurance Company 01/2000 to 12/2008
I started my own Life and Health Insurance company. Hire and trained 30 agents. Advertising and Marketing for varies insurance companies. Market Medicare Advantage, Medicare supplement, 403, annuity, Long-Term Care, final expenses and other insurance products. Telemarketing to private individuals, and business. Cold calling and lead development. Employee Benefits accounts. Cross-selling clients on other products. Medicare open enrollment job fair for employees.
CARES (Center for AIDS Research Education & Services) 03/1990 to 03/1999 Medical Reimbursement Manager
Medical Biller/Financial Intake Counselor
Day to day operational managing AIDS clinic outpatient clinic. Responsible for handling grievances, appeals, or denials including investigating, preparing, and presenting appropriate materials for review. Review patient account for maximizing reimbursement by minimizing financial risk and increasing A/R net revenue by reducing unmanageable debt from write-off; and reducing denials and increasing collection. Focus on patient visits with no insurance or co-pay by reviewing insurance coverage of each patient. Effectively evaluated medically indigent clients referred by contracted agencies for Medi-Cal eligibility. Assisted clients in accurately completing the Medi-Cal application and gathering necessary documentation for submission once eligibility has been verified. Collaborated with county eligibility workers to follow up on pending applications and effectively explained Medi-Cal benefits and the application process to clients. Medical Billing/ Follow–up Specialist (Contract). Collaborate closely with the Social Worker in interview patient regarding the financial issues.
SOFTWARE
SmartCare Insyst Welligent eClincial Works (eCW) EPIC AllScript Paradgon Atlas Spyglass Prime Clinical Office Alley Great Plain McKesson Assurance Reimbursement Management NextGen Secraoms EDI Smart Advisor Microsoft Word Excel Power Point
EDUACTION & CREDENTIALS
B.S. – Pastoral Studies (Cum Laude) Paralegal Certificate
Medical Billing and Coding
AWARDS & RECOGNITION
National Dean’s List Who’s Who’s Among College Students Dean’s List Certificate of License Ministry Certificate of Recognition Women’s Regional Sales Director (Certificate)
Elite Insurance Sales Rep Sales Agent of the Year
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