Certified Medical Billing & Administrative Specialist

Hayley Bell

Clovis, CA 559-***-**** *************@*****.***

PROFESSIONAL SUMMARY

Certified medical billing and healthcare administrative professional with 6+ years of experience in insurance coordination, claims processing, and benefit administration across medical, dental, vision, and pharmacy lines. Expert in appeals, prior authorizations, denial management, and high-volume workflow optimization. Specialized in ABA billing, pharmacy benefit management, and behavioral health services. Proven leader with strong remote work capabilities and track record of exceeding performance standards while maintaining HIPAA compliance.

CORE COMPETENCIES

Medical Coding & Billing: ICD-10, CPT, HCPCS Coding • Medical Coding & Billing Compliance • CPT/HCPCS Modifiers • Claims Submission & Adjudication • Electronic Claims (837/835 EDI) • Clean Claims Processing • Rejected/Denied Claims Resolution

Insurance & Revenue Cycle: Commercial, Medicare & Medicaid • Insurance Verification & Eligibility • Benefits Administration • Prior Authorization & Pre-certification • Appeals & Denial Management • Accounts Receivable Management • Payment Posting • EOB/ERA Processing • Timely Filing • Coordination of Benefits

Specialized Expertise: ABA Billing • Pharmacy Benefit Management • Behavioral Health Coordination • Developmental Disability Services • Medical Necessity Determination • Provider Relations

Technical & Administrative: HIPAA Compliance • EHR/EMR Systems • Medical Billing Software & Clearinghouses • QuickBooks • Microsoft Office Suite • CRM Systems • High-Volume Workflow Management (50+ cases daily) • Staff Training & Leadership • Remote Work

PROFESSIONAL EXPERIENCE

Senior Benefits Administrator Aetna, a CVS Health Company Remote January 2024 - Present

• Administer comprehensive benefits across medical, dental, vision, and pharmacy lines; processed 50+ complex claims daily with above-standard accuracy

• Manage appeals, prior authorizations, and claims examination; verified medical necessity and benefit coverage compliance

• Complete specialized training in ABA billing for autism/behavioral health services; worked directly with ABA providers on billing issues and authorization requirements

• Handle pharmacy benefit management including formulary questions, prior authorizations, and coverage determinations

• Resolve escalated member inquiries and complex benefit issues requiring multi-system research

• Process EOBs/ERAs, applied CPT/HCPCS modifiers, calculated patient responsibility (deductibles, copays, coinsurance)

• Maintain meticulous HIPAA-compliant documentation in CRM systems, ensuring audit readiness

Lead Medical Office Coordinator Power Chiropractic Clovis, CA April 2021–December 2023

• Managed complete front and back office operations for multi-provider practice serving 200+ patients daily; supervised and trained staff

• Oversaw full revenue cycle: insurance verification, claims submission via clearinghouse, payment posting, AR management, collections

• Achieved 95% claim acceptance rate through accurate ICD-10/CPT coding and thorough benefit verification

• Processed Medicare, Medicaid, and commercial payer claims (Blue Cross, Anthem, UnitedHealthcare); ensured timely filing compliance

• Appealed denied claims with supporting documentation; managed accounts receivable aging and payment arrangements

• Processed prior authorizations, coordinated with insurance companies, educated patients on coverage and financial responsibility

• Maintained accurate EHR documentation ensuring HIPAA compliance; streamlined workflows to improve efficiency

Shift Lead Walgreens Clovis, CA October 2020–April 2021

• Provided pharmacy support, including processing prescription transactions and resolving complex insurance coverage issues

• Managed customer escalations related to insurance denials, prior authorization requirements, and billing disputes

• Collaborated with pharmacy staff and insurance companies to resolve coverage issues and obtain authorizations

• Supervised team on HIPAA compliance, register operations, and customer service protocols

• Balanced registers, managed daily financials, and handled cash/insurance co-payments accurately

Case Manager The Arc Fresno/Madera Counties Fresno, CA July 2018–October 2020

• Provided case management for adults with developmental disabilities (autism, intellectual disabilities, schizophrenia)

• Coordinated services with ABA providers, psychiatrists, therapists, and interdisciplinary treatment teams

• Supported clients with employment maintenance, Independent Living Services (ILS) setup, and healthcare navigation

• Attended medical appointments and CVRC meetings; tracked behavioral data and conducted work/behavioral evaluations

• Created individualized service plans, documented progress, determined appropriate support levels (1:1 vs. group)

• Facilitated communication between providers, insurance companies, families, and service coordinators

EDUCATION & CERTIFICATIONS

• Medical Coding and Billing Certification (MCBC) American Medical Certification Association 2025 Valid through 2027

• High School Diploma Buchanan High School 2017

• B.S. Psychology Grand Canyon University 2023 - present (diploma not yet received)

• Additional On-the-Job Training: ABA Billing • Pharmacy Benefit Management • Appeals & Prior Authorizations

ADDITIONAL QUALIFICATIONS

Remote work expertise • Staff training & leadership • High-volume workflow management • Problem-solving in fast-paced healthcare settings • Knowledge of federal healthcare regulations (HIPAA, ADA) • Experience with vulnerable populations and complex care coordination

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