Quality Assurance Accounts Receivable
Resume:
Ronnese Daniel
Quality Assurance and Compliance Professional
Waldorf, MD 20603
********************@*******.***
Professional Summary
A professional in the Human Services field, looking for a position where I can apply 5+ years of analytical, organizational, leadership, clinical, ad training skills to support the growth and wellness of the company. Work Experience
Upfront Review Clerk
Lincare-Remote
February 2025 to Present
• Review customer documentation to process orders for DME equipment (CPAP, Oxygen, Nebulizers, Wheelchairs, etc.)
• Evaluate customer documents to ensure information is appropriate for billing and accounts receivable
• Maintain held sales reports to secure revenue and prevent sales loss
• Verify customer insurance to ensure proper payor codes and eligibility for services
• Document prior authorizations and prescriptions for equipment
• Ensuring document compliance for all equipment and prescriptions (date of service, doctor signatures, customer signatures, correct hcpcs/item codes, etc.)
• Accurately document and communicate account needs in AS400 IBMi Utilization Review Case Manager
Luminis Health-Lanham, MD
April 2023 to Present
• Assesses data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age-specific needs. Maintains monthly statistical data and reports data to Clinical Director.
• Evaluates data obtained in the bio-psychosocial and nursing history and assesses patients and their families to determine by interview, appropriateness for admission or referral.
• Determines the medical necessity and appropriateness of admission, using established criteria and standards.
• Verifies that pre-admission assessment is performed, and pre-authorizes patients as applicable.
• Monitors medical records for medical necessity and appropriateness of continued stay in accordance with established and approved norms.
• Verifies prior authorization data and performs concurrent reviews with external review agents on a daily basis in order to provide medical necessity and intensity of service information for continued stay approvals.
• Consolidates, tracks and reports performance on completed utilization review forms for all clinical areas and relays information to the multi-disciplinary treatment team.
• Resolves matters on outliers and initiates/follows up on appeals for determination at variance with program norm.
Intake Manager/Business Office Manager
PRESTIGE HEALTHCARE RESOURCES
April 2021 to August 2024
• Supervise Intake Care Coordinators to ensure completion of intakes and other clinical services
• Review intake documentation submitted by the intake team to ensure clinical compliance
• Develop policies and procedures to help streamline the intake process
• Monitor the insurance (Medicaid /MCOs) and authorizations for incoming and current consumers
(1,000+)
• Verify consumer eligibility through Medicaid web portal
• Transfer consumer information/demographics from iCams
• Assist consumers with applying for insurance
• Assist with the development and implementation of mental health programs (ACT, CBI, SUD, TST, MST, etc.)
• Facilitate Company trainings for new hires and current employees (documentation, electronic medical record system, quality assurance, etc.)
• Serve as the EMR point of contact to resolve tech requests and training
• Run weekly reports to provide clinical staff and COO with trends that outline the progression or regression of company programs
• Track all incoming referrals and transfers on a spreadsheet communicating process and updates to all department managers
• Collaborate with Housing Team and SUD team to ensure MHRS service provision
• Administrative duties including, but not limited to, consumer demographics, billing claims, running credible reports, trouble shooting credible issues, etc. Quality Assurance and Compliance Analyst
UMBRELLA THERAPEUTIC SERVICES
April 2018 to January 2021
• Develop company wide policies and procedures
• Develop and conduct audit tools to lead internal claims audits
• Develop written reports and summaries to communicate audit findings to the CEO and Executive Team
• Respond to external financial and claims audits conducted by Department of Behavioral Health
• Conduct internal Medicaid fraud investigations
• Develop and administer consumer satisfaction surveys
• Consult with clinical staff on methods of quality improvement
• Develop Performance Improvement Plans/Corrective Action Plans based on identified audit trends
• Supervise Quality Assurance staff
• Review and Approve progress/case notes and all clinical documentation submitted by case mangers, therapists, Psychiatrist, Nurse Practitioners, etc.
• Facilitate Person-Centered Treatment Plan Trainings Quality Assurance Manager
CONTEMPORARY FAMILY SERVICES
October 2016 to April 2018
• Develop company wide policies and procedures
• Develop and conduct audit tools to lead internal claims audits
• Develop written reports and summaries to communicate audit findings to the CEO and Executive Team
• Respond to external financial and claims audits conducted by Department of Behavioral Health
• Conduct internal Medicaid fraud investigations
• Develop and administer consumer satisfaction surveys
• Consult with clinical staff on methods of quality improvement
• Develop Performance Improvement Plans/Corrective Action Plans based on identified audit trends
• Supervise Quality Assurance staff
• Review and Approve progress/case notes and all clinical documentation submitted by case mangers, therapists, Psychiatrist, Nurse Practitioners, etc.
• Facilitate Person-Centered Treatment Plan Trainings Social Work Internship Experience
AprilMay Company Inc.
•Conduct intake and psychosocial assessments to determine the needs of the consumers
•Provide Therapeutic Psychiatric Rehabilitation services to children and adults diagnosed with a mental illness
•Assist clients with meeting goals identified in their rehabilitation plan
•Document the progression/regression of each consumer
•Provide consumers with city resources (food, shelter, housing assistance, supported employment, financial assistance, education, etc.)
•Collaborate with parents, social workers, teachers, doctors, psychiatrists, etc., for continuity of care Education
Child and Adolescent Studies (Bachelor's)
BOWIE STATE UNIVERSITY
2013
Skills
• Typing
• Records management
• Medical collection
• Epic
• Human Resources
• Leadership
• Process Improvement
• Medical office experience
• ICD coding
• Interviewing
• Conflict management
• EMR systems
• Computer skills
• Patient interaction
• Organizational skills
• Administrative Experience
• Analysis skills
• Compliance management
• Insurance prior authorization
• Employee Orientation
• Case Management
• Medical Records
• Insurance verification
• Data entry
• Microsoft Word (10+ years)
• HCPCS
• Computer literacy
• Training & development
• Microsoft Office
• Discharge planning
• Microsoft Outlook
• Microsoft Teams
• ICD-10
• Data analysis skills
• Microsoft Powerpoint (10+ years)
• Employee Evaluation
• Internal audits
• Office Management
• Social Work
• Customer service
• Communication skills
Certifications and Licenses
CPR Certification
Certified Case Manager
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