Utilization Management & Medical Billing Specialist
Resume:
Houston, USA
TIA SMITH
Summary
Detail-oriented healthcare professional with extensive experience in utilization management, medical claims processing, and provider/member services. Skilled in prior authorizations, medical necessity review, benefits verification, and claims adjudication, with a strong understanding of ICD-10, CPT, HCPCS coding, HIPAA, and CMS guidelines. Adept at collaborating with providers, payers, and patients to ensure accurate claims resolution, compliance, and high-quality service. Seeking to leverage expertise in healthcare operations, customer service, and process improvement to contribute to organizational efficiency and positive patient outcomes.
Skills
Experience
Billing Specialist
Reliant Healthcare Group
Houston, TX 77084 832-***-**** ***************@*****.***
• Utilization Management (UM)
• Prior Authorizations
• Medical Necessity Review
• Medical Claims Processing
• Adjudication
• EOBs
• Appeals Resolution
Healthcare Policy & Compliance (HIPAA, CMS
Guidelines)
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• ICD-10
• CPT
• HCPCS Coding Knowledge
• Insurance Eligibility & Benefits Verification
• Provider & Member Services
• Patient Advocacy
• Call Center Support
Electronic Medical Records (EMR/EHR)
Systems (Epic, Cerner, Facets, Availity)
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• Data Entry Accuracy
• Quality Assurance
• Process Improvement
• Strong Communication
• Conflict Resolution
• Customer Service Skills
• Time Management
• Multitasking
• Cross-Functional Team Collaboration
• Medical coding
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Managed full-cycle medical billing using multiple EMR/EHR and revenue cycle platforms, including Epic, Raintree, CentralReach, PointClickCare, KanTime, Availity, Waystar, and TMHP.
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Verified insurance eligibility, benefits, deductibles, copays, and coinsurance through payer portals and clearinghouses to ensure accurate billing and patient responsibility.
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Submitted, monitored, and corrected high-volume claims for commercial, Medicaid, and managed care payers using CPT, ICD-10-CM, and HCPCS coding standards.
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Researched and resolved claim denials and rejections by reviewing EOBs/ERAs and submitting appeals and corrected claims through Availity and Waystar.
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Coordinated prior authorizations and re-authorizations to support uninterrupted therapy services and prevent revenue loss.
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Posted and reconciled payments, adjustments, and contractual write-offs within EMR and billing systems.
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Communicated effectively with insurance representatives, providers, and patient families regarding billing inquiries, balances, and payment plans.
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• Maintained compliant, audit-ready documentation across all billing and clinical systems. Reduced accounts receivable aging through consistent follow-up, payer outreach, and workflow optimization.
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• Supported revenue cycle performance by meeting accuracy, productivity, and compliance benchmarks. 10/2020 to 05/2025
Houston, USA
06/2016 to 10/2020
Houston, USA
10/2014 to 06/2016
Houston, USA
Utilization Management Representative
Elevance Health
Claims Processor
Elevance Health
Customer Service Representative
Elevance Health
Manage incoming and post-service claim workflow including prior authorizations, pre-certification inpatient admission, outpatient treatment, and post-service review requests to ensure compliance with contract and benefit eligibility requirements.
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Conduct clinical screening of provider requests; gather and verify applicable documentation, medical records, treatment plans, demographics, and eligibility information to determine medical necessity.
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Use Utilization Management (UM) systems to log, track, and update referral or authorization request data in accordance with plan policies and guidelines.
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Determine contract and benefit eligibility for members; communicate authorizations for inpatient and outpatient care; refer complex or clinical cases to Nurse Reviewers or clinical leadership when required.
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Respond to provider, client, and internal department inquiries via phone, email, or written correspondence; maintain strong relationships and ensure timely resolution of utilization or authorization issues.
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Perform benefit verification and eligibility checks, including for facility-based treatments; assist providers or members in understanding coverage, benefit limits, policy limitations, and UM guidelines.
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In more advanced roles, handle specialty care and complex requests; follow up with providers for missing information; act as liaison between Medical Management and internal departments.
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Maintain accurate documentation and records; ensure adherence to regulatory, contractual, and accreditation standards (URAC, HIPAA, etc.); uphold quality assurance and SLA / turnaround time goals.
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Accurately reviewed and processed a high volume of medical, dental, DME, and/or pharmacy claims in accordance with plan benefits, provider contracts, and regulatory guidelines.
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Verified member eligibility, provider status, and coverage policies to determine claim accuracy and appropriateness.
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Applied CPT, ICD-10, and HCPCS coding knowledge to validate clinical data and adjudicate claims properly.
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Researched and resolved complex or denied claims through investigation and coordination with providers, billing offices, and internal departments.
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Maintained high productivity while consistently meeting or exceeding quality assurance benchmarks and turnaround time standards.
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Documented claim activity clearly and thoroughly in claims processing systems (e.g., Facets, Xcelys, & Amysis).
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Ensured compliance with HIPAA regulations and maintained confidentiality of protected health information (PHI).
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Supported audits, appeals, and adjustments by gathering supporting documentation and preparing claim summaries.
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Provided high-quality support to members and providers by responding to inquiries related to health insurance benefits, coverage eligibility, claims status, billing, and prior authorizations.
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Accurately interpreted and explained complex plan benefits across Medicare, Medicaid, and commercial products in a clear and empathetic manner.
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Resolved escalated issues by researching claims discrepancies, coordinating with internal departments, and ensuring timely follow-up and resolution.
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Educated members on preventive services, cost-saving programs, and in-network providers to improve care utilization and satisfaction.
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Documented all interactions in CRM and claims processing systems (e.g., Facets, QNXT, HealthEdge) in compliance with HIPAA and organizational guidelines.
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Chicago, IL
Chicago, IL
Education and Training
Associate of Applied Science: Health Information Technology DeVry University Chicago Campus
Graduate
Diploma: Medical Billing And Coding
DeVry University
Certifications
Certified Coding Specialist
Met or exceeded departmental KPIs including call handling time, first-call resolution, customer satisfaction, and compliance audits.
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Participated in ongoing training to stay updated on policy changes, regulatory requirements, and system enhancements.
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