Data Entry Quality Assurance

Nycole Washington

Role at BerryDunn: Consultant with BerryDunn since March 2022

Certifications and Education: Associates of Applied Science, Computer and Network Administration, Remington College

Overview

Dedicated Claims Representative with 20 years of experience in the healthcare industry. Her background includes processing and auditing Medical (professional, hospital), Dental, Medicaid, Medicare claims for payments, adjustments, data entry, refunds and interpreting network pricing. She was responsible for performing quality assurance reviews in accordance with guidelines, and has developed excellent analytical, organizational, and communication skills. Relevant Experience

BerryDunn (April 2022 to present). Consultant with BerryDunn’s Medicaid Practice Group

(MPG)

West Virginia Bureau for Medical Services (BMS)

• Fee Schedule and Edit Quality Review Project (April 2022 to present). Serves as a Subject Matter Expert (SME) for the project. I focus on evaluating the MMIS fee schedules and claim edits to ensure MMIS setup complies with Medicaid policy and to provide analysis of cost-savings opportunities for BMS.

• Payment Error Rate Measurement (PERM) RY2023 Project (April 2022 to present). Serves as a project SME for the PERM project. I focus on validating data processing and medical record errors, researching error remedies and providing recommendations for resolution of PERM errors cited for West Virginia.

• Public Health Emergency (PHE) Support Project (April 2022 to present). Provides project support through research to assist West Virginia return to normal operations, once the PHE ends.

NCI Company (March 2017 to March 2022). Worked as a Lead Medicaid Reviewer with CMS’s Payment Error Rate Measurement project, where she developed performance standards for less experienced staff to meet CMS metrics/timeliness requirements, worked with Medicaid staff to set goals, develop processes, and set timeliness, and collaborated with IT staff to gain access and troubleshoot problems that prevent access and troubleshoot problems that prevented access to state MMIS for direct reports. I supported team members with review of exceptions and resolution of conflicting findings from lower-level reviewers while also working one to one with less experienced reviewers to develop individualized standards involving claims processing, authorization, and payment. This required reviewing individual outcomes against these standards and collaboratively developing an individualized corrective plan. I researched complex review situations, analyzed multiple claim processing, eligibility enrollment, and provider enrollment systems, and made informed decisions to determine if the information in all systems resulted in an accurate payment determination. I consulted with management and staff stakeholders the implication of how state and federal polices and regulations were applied in differing claims scenarios. In addition, read, interpreted, and applied complex federal and state regulations and their impact to claim processing. I suggested revisions to any impacted work products or standard operating procedures as a result of changes in federal or state regulations impacting Medicaid claims payment accurately. I conducted audits of claims processing systems across the country, worked closely with the state liaison to determine missing items to complete review, and analyzed Federal and State regulations / policies for Medicaid and CHIP reimbursements. I determined if monies paid by the states were made in accordance with Federal and State policies for Medicaid and CHIP. For each state, she performed audits accessing several systems and applications, such as MMIS, PECOS, Citrix, QNXT and Facets while maintaining the confidentiality of patient information in accordance with HIPAA regulations and participating in entrance and exit conferences with key personnel in state Medicaid agencies. She also participated in drafting and producing monthly and end-of-review period reports and identified and reported potential fraud discovered during the audit process. Star Administrators (November 2015 to March 2017). Worked as a Claims Analyst to adjust and process claims (medical, Medicaid) as the main customer service contact to resolve issues and identify customer needs in a proactive manner. I reviewed and processed insurance to verify medical necessities and coverage under policy guidelines, utilized systems to track complaints and resolutions, and verified correct plan loading. BroadPath Healthcare Solutions (July 2014 to November 2015). Worked as a Claims Processor to manage UB and HCFA claims, check claims to make sure each claim processed correctly according to the benefits and plans, and maintain quality and production goals. Also, I adjusted claims due to corrective billing or additional charges. Dell Inc. (September 2013 to July 2014). Worked as a Senior Claims Operations Associate to reprocess claims for United Health Care applying correct Medicaid rates. I assisted with training of staff on COB and Medicaid claims, and served as point of contact for questions from team members.

REDC Default Solutions LLC (January 2012 to September 2013). Worked as an Operations Assistant to manage sensitive information utilizing appropriate macros. I captured credit scores to upload for reporting, uploaded documents to internal/external systems, verifying for accuracy, and tasked files in Equator system to appropriate status. I provided quality assurance reviews, created various reports that consisted of aged files, monitoring of files for compliance, and wrote Welcome/Decline/Solicitation Letters. Also, I processed incoming daily mail and monitored fax boxes and emails from the Borrower and/or the Agent BlueCross and BlueShield of Texas (May 2011 to August 2011). Worked as a Claims Examiner to research claims for refund. I adjusted Medicare, COB claims due to other insurance paid primary; adjusted claims paid due to billing errors; adjusted claims that were paid due to duplicate payments; and adjusted Workers Comp claims to apply due to reimbursement Unicare Insurance (October 2000 to July 2010). Worked as a Claims Representative to process UB and HCFA 1500 Claims, obtain the contracted allowed amount from Unicare’s rental network partners, and monitor the timeliness of the claims for their networks. I worked with the network contacts on outstanding claims, providing claims payment status and check information, and responded to emails, faxes and correspondence to obtain the appropriate information, as well as the utilizing WGS and STAR systems to apply updates. She processed claims according to their benefit profile and Explanation of Benefits and adjusted claims while performing extensive data entry. She keyed in professional, hospital claims in WGS and STAR systems and used Pinnacle, Citrix, Hanstar.

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