Manager Medical
Resume:
APRIL LACHELLE SMITH
Jacksonville, Florida 32218
***********@*****.***
EDUCATION
• AAPC Approved 80 Hour Medical Coding Course
• Health HIT Workforce Training Accelerated Program – Practice Workflow and Information Redesign Specialist
HEALTHCARE CERTIFICATION
• Certified Professional Coder
SUMMARY OF QUALIFICATIONS
• 13+ year’s medical billing, coding, auditing and claims reconciliation.
• Extensive knowledge of Medical Coding guidelines and coding techniques (CPT, ICD-9, HCPCS, Medical Terminology)
• Proficient in physician and outpatient coding.
• 14+ year’s health insurance experience.
• Knowledge of various products and lines of business (e.g. HMO, PPO, POS)
• Very efficient in Microsoft Office Software: Word, Excel, PowerPoint, Publisher, Outlook, and Access.
• Type 50 wpm with accuracy.
• Strong data entry skills - 10,000+ kph with accuracy.
• Effective communication, interpersonal and organizational skills.
WORK EXPERIENCE
Community Hospice of Northeast Florida 03/10 – Present
Coding/Reimbursement Specialist
• Performs audits of provider documentation and coding to ensure accurate billing for Medicare, Medicaid, and third party payors.
• Develops, maintains, and revises audit tools.
• Independently completes documentation audits within established timeframes, analyzes results and prepares formal reports with findings and recommendations.
• Provides monthly reports to the Risk Manager regarding audit results. May also provide audit results to the Chief Medical Officer as directed.
• Provides education to providers in regards to documentation for reimbursement and compliance.
• Identifies focus areas related to audit findings, claim denials, or known pre-payment reviews.
• Designs and presents appropriate education to address identified needs.
• Schedules opportunities for one-on-one teaching in the patient care environment.
• Develops assessment tools in conjunction with the Risk Manager to determine effectiveness of coding/documentation education.
• Reports results of education to the Risk Manager and may report results to the Chief Medical Officer as directed.
• Coordinates the Medical Records Department process for tracking the clinical documentation and patient census for the palliative care program.
• Develops, maintains, and revises charge forms, including superbills and evaluation and management (E&M) coding cards and other forms/templates required to facilitate the provider billing process.
• Responds to coding and compliance questions from providers, the Finance Department, and others.
• Collaborates with the Finance Department to resolve complicated coding issues or claim rejection for Medicare, Medicaid and third party payors related to physician billing.
• Processes additional documentation request received from Medicare, Medicaid and third party payors related to physician billing.
• Conducts medical record review related to the additional documentation request.
• Coordinates the additional documentation request process including maintenance of tracking logs and preparation of cover letters as required.
• Provides monthly reports to the Risk Manager regarding the status of additional documentation request.
• Reviews claims denied by Medicare, Medicaid and third party payors for physician billing.
• Prepares appeals of denial as appropriate based on the review of the medical record and coverage criteria.
• Coordinates the appeals process including maintenance of tracking logs and throughout the review process.
• Assists management with special projects and performs other duties as may be required to support the organization’s physician billing and compliance program.
University of Florida Jacksonville Physicians 06/06 – 04/11
Reimbursement Analyst
• Compiles and analyzes data pertaining to reimbursement issues by preparing periodic and on-demand reports pertaining to reimbursement issues in which serves as a reimbursement information source for providers and staff.
• Auditing of medical records for multiple specialties includes Surgery, Anesthesia, Emergency Medicine, Primary Care, Radiology, Pathology, Pediatric and OB/GYN.
• Assists Director of Clinical Data Quality and Manager of Reimbursement and Education with special projects as assigned such as fiscal budgets for all multiple specialties.
• Acts as liaison between business groups and manager and help to provide professional guidance needed to resolve coding and documentation problems.
• Supports the Reimbursement/Education Manager in all functions to ensure compliance with all regulatory guidelines related to coding and fees.
• Prepare, publish, and distribute fee schedules (paper) by processing fee requests as appropriate. Routinely update and maintain provider fees/fee schedules in computer system and commercial and government carrier allowable schedules in computer system.
• Compiles daily/monthly reports that affect multiple departments or areas related to reimbursement issues.
• Remain current on all coding and reimbursement issues, research and analysis for coding related projects.
Supervisor of Primary Care Business Group 04/03 – 06/06
• Established and implement quality assurance processes by monitoring staff activities assuring that the department goals are met.
• Interacted with staff to seek resolution to problems/issues.
• Maintained statistics for production and accuracy.
• Managed employee scheduling to ensure smooth work flow by providing effective communications with staff regarding changes or updates to be implemented within the department.
• Provided disciplinary/corrective action as necessary within the department while communicating these issues to the Business Group Manager.
• Provide effective communication with other departments as needed to ensure the requests for research from other departments are performed accurately and in a timely manner.
• Provide feedback to Manager with collection issues, reimbursement trends, personnel issues, and operational issues within the department by developing and submitting plans for operational improvement.
Special Biller for Department of Cardiology/CT 10/97 - 04/03
• Contacted insurance companies to ascertain the status of claims and identify additional information needed.
• Researched and take appropriate action in regards to refunds, charge corrections, etc. with the ability to identify refund trends, as assigned.
• Documented notes in the automated billing system regarding patient inquiries, conversations with insurance companies, clinics, etc. for all actions.
• Re-filed insurance claims when necessary to the appropriate carrier based on each payors specific appeals process with the knowledge of timelines.
• Completed correspondence requests through interaction with payers, patients and/or the clinics to provide needed information for claims payment and worked aging.
• Identified payer issues and trends by payer that impact A/R and communicate to leadership (denials, payment transfers, etc.)
• Data and charge entry for Research Grants. Complete special projects assigned by the Team Leader and perform other, related duties as assigned by Team Leader or Manager.
REFERENCES AVAILABLE UPON REQUEST
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