Experience

• 

  Health advocate

  May 2012 - Oct 2013

  Claims specialists/medical cost negotiator

  • Managed accounts to resolve multiple payers’ issues, problematic and special accounts, credit balance and refunds.• Research and Investigate relevant claim and billing issues related to payment, denials, adjustment errors and misrouted payment.• Review plan documents and contract to determine the best course of action• Verify insurance eligibility, benefits, co-pay collections, patient responsibility and pre-certification.• Negotiate Consumer/Member Medical Claims with Healthcare Providers.Develop and implement balance settlements, calling providers for detailed information regarding possible payment terms, and documenting any savings.Maintain a solid relationship with customer, providers, internal staff and management.Documents claim file actions and telephone conversations appropriately.Respond to customer questions related to Benefit Plans (i.e. medical, dental, life, STD, LTD), consumer-driven health plans, FSAs, provider selection, qualifying life events and the open enrollment process within required timeframe Extensive Knowledge of CPT, ICD-9, HCPCS coding, managed care, commercial plans and billing procedures Show less

• 

  Community behavioral health

  Nov 2013 - Oct 2018

  Build and Maintain a strong functional team through effective recruiting, training, performance management, coaching, team building and succession planning. Develop onboarding model for new staff upon hire.Monitor individual and team performance to ensure quality performance objectives are met through key performance indicators (KPI). Ensure that department meet all claims payment requirements as specified in the CBH Provider Agreement, DPW and CMS standards. Foster and Encourage a culture that promotes clear and precise communication, continuous improvement and employee engagement.Monitor and Audit all claims activity within the information system to ensure correct claim edits and business rules are working accurately. Implement internal controls, create and mandate policies and procedures to ensure consistency and standardization for automated billing process related to the claims management system.Assist in backlog reduction, client contact on claim issues, client/provider education, and interdepartmental communication to expedite claim handling.Direct and Manage finance and clinical based project initiatives related to the program standards related to the Department of Mental Health Intellectual Disability for Community Behavioral Health. Implement new policies and procedures for Third Party Liability department to maximize efficiencies of team task to ensure compliance are within federal and state guidelines. Oversight of vendor relationship and participate in payor meetings whenever needed. Communicate with Senior Management concerning in new program changes. Provide guidance to TPL departmental staff regarding resolving inquiries involving billing discrepancies, eligibility and insurance related issues. Show less Build and maintain a strong functional team through effective recruiting, training, performance management, coaching, team building and succession planning.Monitor individual staff performance and ensure quality and quantity performance objectives are met.Ensure that all paper claims are processed in accordance to first in, first out.Ensure that all completed appeals and adjustments are filed according to the document destruction policy.Ensure that all completed claims are sent for microfilming within established time and returned microfilm is reviewed for quality.Ensure that department meets all claim payment requirements as specified in the CBH Provider Agreement or by DPW and CMS.Develop best practices to optimize claims process.Prepare monthly reports for Chief Finance Officer and Chief Executive OfficerMaintain all initial request and loading into Business Rules Management system. Show less Establishes appropriate goals and performance standards.Accountable for the staff and activity within the claims department. Develops claims processing guidelines and training programs for staff.Ensures that claims are processed accurately and timely.Prepares monthly reports as needed t comply with Department of Public Welfare requirements.Prepares and maintains all employee documentation including timesheets, performance appraisals, disciplinary records, etc.Ensures that department meets all claims payment requirements as specified in the CBH provider agreement or by DPW and HCFA. Show less Performs detailed analysis of authorizations and rejections to determine potential liability to the provider.Identify billing errors and recommend solutions to providers that will effectively streamline their EDI billing process.Monitors and analyze provider’s billing practices to ensure accurate claim submission and adjudication.Research and investigate complex billing issues related to late submission appeals, claim denials, EDI claim edits to ensure payment resolution. Assist in overriding late submission, eligibility, TPL claims and claim adjustments. Show less

  • Third Party Liability Manager

    Mar 2017 - Oct 2018

  • Interim Assistant Director of Claims Department

    Dec 2016 - Mar 2017

  • Claims Manager

    Jan 2014 - Dec 2016

  • Claims Supervisor

    Dec 2013 - Jan 2014

  • Senior Claims Analyst

    Nov 2013 - Dec 2013
• 

  Self-employed

  Nov 2018 - now

  Chief visionary officer

  Kidz Konnectionz Educational Center is committed to building strong communities and strong families while investing in the lives of our youth.

• 

  Ori homecare

  Oct 2019 - Mar 2020

  Revenue cycle manager

  Manage the daily operations of the Front End, Billing, Collections, Cash Posting, and Denial Management Teams. Ensure that billing specialists are billing/collecting all claims in a timely manner. Keeps abreast of all reimbursement billing procedures of third party, private insurance, and government regulations to ensure compliance with current processes.Ensure that Revenue Cycle Management Specialists follow up on outstanding items and assist in resolution of billing audits. Monitor and ensure that Home Health Platform is up to date. Responsible for weekly/monthly/status reporting (development/preparation/maintenance of reports. Develop procedures and work practices designed to maximize performance and overall collection activities. Conduct routine scheduled meetings with staff to ensure consistency, on going education and training. Evaluate staff performance and take corrective actions in accordance with departmental HR guidelines. Monitor, maintain, and develop workflows to reduce collection backlog. Show less