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Click here or scroll down to respond to this candidateCandidate's Name
Rowlett, Texas Street Address
Cell PHONE NUMBER AVAILABLEEmail: EMAIL AVAILABLESummary of QualificationsOver 20 years of experience in the Healthcare/Medical industry.10+ years of Health-rule Payor and Claims Processing10+years of Medicare compliance and regulationsKnowledge of ICD-10 codesPerfect knowledge of Medical Terminology.Able to identify problems and find solutions, face challenges head on.Quick and eager to learn; conscientious and detail-oriented.Knowledge of Hospital and Benefit contract structure and language.Demonstrated ability to adapt quickly and manage a rapid changing environment.Professional BackgroundDell Services/NTT Data 1/2013 presentClaims Processing Operations UnitMedicare AdvantasureProcess Training Specialist 7/21- presentCreate and design a Training Program that would successfully train and educate Claims Processors on the basic knowledge of claims processing and the IKA system for Medicare Advantasure Local and ITS.Coordinate with the client on written instructions for the Desk Level Procedure (DLP) process on seven different Medicare Advantasure clients.Perform QA Departmental Audits on newly trained Processors.Implementing changes to our internal Processing Manuals.Train, coach and develop employees to surpass company objectives and standardsWorked and mentored Unit Leads and provided support to the Supervisor and Manager as neededServed as the Subject Matter Expert for departmentsClaims Processing Operations UnitClaims Supervisor 10/18 7/21Supervised two units of Claims Processing and Provider EnrollmentResponsible for all departmental Corrective Action Plans (CAP)Tracked and evaluated individual performance.Oversaw the day-to-day staffing needs of the department.Maintain accountability for team performance and proactive with process change.Oversaw theAudit and Training
Lead Quality Assurance Analyst 1/13 10/18Performed pre-pay, post-pay and IKA system audits on Medicare Advantage claims in the IKA System for Local Medicare Advantage and ITS Blue-card claims.Responsible for Root Cause meeting and assessment of Claim errors and resolutionResearched audit report accuracy and responds to audit appeals to ensure a successful resolution.Trailblazer Health Enterprises, LLCCMS Medicare Mac J4 10/2006 12/2012Part A & B Hospital Claims UnitClaims Unit Lead /Trainer IIProcessed, Medicare hospital and professional claimsResponsible for updating Internal and External written work instructions for claim pends and claim processing edits.Supervised three different team of Claims Examiners to ensure claim production was being met in a timely manner to meet CMS processing requirements.Attending CMS monthly meetings to discuss an operational plan for Change Requests and Transmittal plan process.Served as liaison between Claims department and CMS on claim and system issues as well as quality updates done on a quarterly basis.Assisted management with review and changes with SAS audits and other type of audits that would be sent from CMS.System tester on new system pends and edits as well as claim changes before goingBlue Cross and Blue Shield of Texas, Inc. 7/1996 7/2006Facility Provider Network DepartmentProvider Relations Representative SpecialistCreated training workshops for Hospital Providers on claim billing guidelines and processing across the state of Texas.Assisted providers/hospitals in resolving claim and inquiries relating to pricing, coding and Managed Care contract issues claims billed on UB/1500 claim forms.Corresponded with the Finance Department on benefit changes, loading rates, and system issues related to how hospital and physician claims are paid and reimbursed.Created Benefit Plan Contracts in coordination with the Legal DepartmentResearched legal paperwork for correction of benefits and group benefit plans on HMO, Best Choice, BluCard (ITS) and Manage Care Contracts.Reviewed all plan documentation utilizing legal information provided for processing and completion of HMO and Manage Care contracts.Education: Lubbock High School; Lubbock, TexasHealthcare Management - Richland CollegeCertificates: Claims Coding Certificate Concorde College; Dallas TexasSix Sigma Training White & Yellow BeltOperating Systems: IKA processing system, Nasco processing system, Blue-Square ITS system, BlueChip, PIPP & PAPP pricing system, Premier pricing system, and CMS FISS processing systemApplications: Microsoft Word, PowerPoint, Microsoft Excel, Novell, Lotus cc: Microsoft Outlook, Microsoft PowerPoint |
