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Provider Claims Liaison

Location:
United States
Salary:
60,000
Posted:
September 21, 2008

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Resume:

Mona Lisa Reichard, 914-***-****

E-mail - gqrij5@r.postjobfree.com

Objective: Provider Claims Liaison.

Skills:

* ******** ******* *** ***** Terminology.

* ******* ** ******* *** solve complex claims issues.

3 Know how to calculate DRG.

4 CPT-4 and ICD-9 coding knowledge.

5 Effectively Communicate with Providers and Hospital staff, and resolve their issues.

6 Outstanding writing skills.

7 Excellent Customer Service skills.

8 Knowledge of Macess system.

9 Knowledge of GMIS System.

10 Knowledge of Amisys System.

11 Knowledge of MHS System.

12 Knowledge of Lexis Legal System.

13 Knowledge of Medisoft software.

14 Knowledge of Microsoft Office.

15 Knowledge of Microsoft Word.

16 Knowledge of Microsoft Excel.

17 Knowledge of Access.

18 Epaces

19 Powerque

20 Carestep

21 CMS Reimbursement Methodologies

Professional Achievements:

Claims:

1 Keyed and resolved approximately 350 claims per day while maintaining 100% financial and statistical accuracy.

2 Processed complex claims in three months.

3 Promoted to Senior Claim Analyst in four months, which usually takes about a year.

4 Processed claims for many states; New York, New Jersey, Maryland, and Texas.

Quality Improvement:

1 Contributed greatly to the development of the claims training procedures for a major NYC Medicaid HMO.

2 Set the standards for claims productivity at a major NYC Medicaid HMO.

3 Help to improve the professional quality of the workplace of a major NYC Medicaid HMO.

4 Improved the appeals resolution time at a prominent Westchester Medicaid HMO.

5 Identified overpayments due to duplicate claims processing and system errors at a prominent Westchester Medicaid HMO.

6 Identified fraudulent billing at a prominent Westchester Medicaid HMO.

7 Created the Claims Audit Manual for a prominent Westchester Medicaid HMO.

8 Implemented the explanation of payment messages for providers, which improved provider relations for a prominent Westchester Medicaid HMO.

9 Utilized HPN to gather information for proper claim payment, and also provided updated information to Provider Relations Department such as; Rules and Regulations, Policies and Procedures, and Guidelines, so that Compliance is met.

Appeals:

1 Created Appeals Department and all Policies and Procedures of the Appeal Department

2 Created Appeal letters for a prominent Westchester Medicaid HMO for a prominent Westchester Medicaid HMO

3 Created Appeal Tracking System for a prominent Westchester Medicaid HMO via computer and hard copy files.

4 Created Appeal Policy and Procedures at a prominent Westchester Medicaid HMO.

5 Solely responsible for responding to all appeals and correspondence for a prominent Westchester Medicaid HMO’s participating and non-participating providers.

6 Implemented messages for explanation of payments for a prominent Westchester Medicaid HMO Providers.

Cost Control:

1 Updated Fee Schedules for a prominent Westchester Medicaid HMO that weren’t updated since 1999 so that claims would pay accurately and reduce pended claims which the Company is financially penalized for.

2 Identified overpayments of inpatient hospital claims at a prominent Westchester Medicaid HMO.

3 Identified duplicate claims processing at a prominent Westchester Medicaid HMO.

4 Implemented the proper procedural coding and modifier used for payment under the Vaccination for Children’s Program for a prominent Westchester Medicaid HMO.

Work History:

7/2005-12/2007: Community Choice Health Plan

Claims Coordinator, Provider Relations: Manage daily claims operations. Maintained all financial records of claim payments, and adjustments. Created Appeals Department and filing system for appeals department via hardcopy and computer files. Facilitate rate negotiations with providers and facilities. Solely responsible for resolving all provider appeals and grievances within the mandated timeframes. Direct outside vendor how to process claims, how to apply fee schedules, and policies and procedures for correct reimbursement. Generate weekly, monthly and quarterly reports for tracking and trending claims activity. Retrieve codes, fees, and new policies and procedures via Medicaid, Medicare, and HPN websites. Updated fee schedules that were outdated since 1999, which enabled the company to pay claims that were on hold for pricing as far back as 2000, and prevented the company from losing more providers who were threatening to disenroll. Educate Providers on the correct way to submit claims for reimbursement. Keep a prominent Westchester Medicaid HMO current in regards to compliance via legal authorities, such as article ten and eighteen of the N.Y.C.R.R. Correspond directly with Attorney General and providers on all unresolved claims issues. Work special projects for Chief Operating Officer, and Chief Compliance Officer. Answer provider inquiries via telephone and written correspondence. Audit claims on outside vendor, and train the analysts how to accurately process claims. Track system and claims processing errors; advise how to correct system issues to improve quality assurance. Attend executive level meetings to discuss any new or outstanding claims, system, provider or legal issues and provide feedback toward the resolution of those issues.

Identified overpayment of both medical and hospital claims, which saved the Company an enormous amount of money. Identified up-coding and down-coding of codes which the company was paying in duplicate. Worked closely with the IT Department to implement system changes to identify, and deny claims that were being billed in duplicate. Created Claims Audit Guide for prominent Westchester Medicaid HMO to assist Upper Level Management in understanding claims processing. Keep Medical Management current on new codes, and coding procedures as well as policies on what is covered for payment, so that Medical Management can effectively correspond with the providers for authorizations. Explain payment and coding methodologies to Provider Relations. Keep providers current with new policies and procedures from the state so that they will understand the reason for amount of payment of denial of claims.

1/2005-6/2005: Affinity Health Plan

Claims Analyst: Enter and adjudicate medical and hospital claims for the City of New York. Processed claims with complicated authorizations. Identify process, adjust, and correct incorrectly adjudicated claims. Advise upper management how to resolve those issues system and claims processing errors. Void, reinstate, cash, and stat adjust claims. Calculate claims via DRG, and high dollar claims for various hospitals; New York Eye and

Ear, New York Presbyterian, Montefiore, and many others. Correspond with providers via phone and mail to resolve complex claims issues. Work special projects. Created new training procedures for claims, which were implemented into the Claims Department by the Director of Claims. Helped to improve the quality of the workplace.

2001-2003: FGI Incorporated Virginia Beach, Virginia

Telephone Interviewer: Make calls to homes and corporations and persuade client to take time to answer surveys approximately a half hour in length in order to obtain statistical data for marketing purposes. Worked on special projects for Verizon, Cingular and Simmons surveys. Maintained outstanding number of completed surveys.

1997-2000: Amerigroup Corporation Virginia Beach, Virginia

Senior Claims Analyst: Process claims and work special projects for various markets; Dallas, Fort Worth, Houston, Maryland, and New Jersey. Enter and process HCFA’s UB92’s NHIC, EDI, surgery, anesthesia, newborn, inpatient, high dollar, hot provider, and claims with complicated authorization issues. Identify process, adjust, and correct duplicated or incorrectly adjudicated claims. Void, reinstate, cash, and stat adjust claims. Create and maintain current phone-logs in order to enter, modify, or verify member or provider information from correspondence received from providers and members into computer system. Assist Team Leader with training new team members. Promoted to Senior Claims Analyst in four months.

1992-1996: 2Gals Paint Queens, New York

Entrepreneur: Owner Operator

1990-1991: United States Navy

Airman, Honorable Discharge

Education:

1997-1998: ECPI School of Technology Virginia Beach, Virginia.

Medical Office Computer Specialist, Honor Graduate.

1992-1994: Stenotype Academy New York, New York

Paralegal Associates Program, Deans List, GPA 3.76

Present: Bachelors Degree Pending

Volunteer Experience:

1996-1997: Sentara General Hospital Virginia Beach, Virginia.

Front Desk Registrar, Admissions, Billing and Coding Department.

Awards Received: Eleven Awards Received from Amerigroup Corporation.

References: Available Upon Request.



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