| | | 20,000+ Fresh Resumes Monthly | |
|
|
| |
Click here or scroll down to respond to this candidateCandidate's Name
PHONE NUMBER AVAILABLE EMAIL AVAILABLE Henrico, VA Street Address
PROFESSIONAL SUMMARYTo acquire and become a contributing team player, within a goal oriented company that will utilize my experience, skills and education, in the healthcare community. SKILLS Word ProcessingExcelAccounts PayableMicrosoft OfficeMedical BillingCPT/ICD 9/10-CM codesInsurance VerificationData EntryPhone lines/switchboardPeopleSoftMysis TigerMedical TerminologyClaims processingCobius Denial ManagerHealthlogicKronos Time EntryBPM FrameworkTriMedNextgen (Pega)CirtixScheduling AppointmentsOral and WrittenCommunicationMedicare inquiryPoint of CareWeb insure exchangeCollectionsRegistrationPre AuthorizationCernerMidasWORK HISTORYApril -2021-PresentRichmond, VAAppeals Team Lead/ Universal Health Services- UHS* Serve as a support person for the Appeals Department by answering questions and addressing concerns. Coordinates training of new hires and provides in-services as appropriate* Work with Appeals Manager to resolve issues associated with denials between other internal departments or external departments of the facilities served* Work in conjunction with Appeals Manager to review open and closed denials to monitor trends at individual facility level to assist with denial avoidance, by providing feedback* Assists Appeals Manager in providing regular feedback to staff related to performance using reviews of productivity and quality of work April-2020-April 2021Richmond, VAApril-2018-April -2020Richmond, VA* Establish and build relationships with major payer representatives at third party insurance companies, and key contacts within Case Management departments within each facility* Review and/or create daily, weekly and monthly reports as assigned* Assist department manager and assistant director with developing individual and group departmental goals and objectives*Review time and PTO request*Conduct high dollar reviews for AR reports*Enter time sheet- punch details for team members*Complete other duties and task as assigned.Appeals Specialist/ Universal Health Services-UHS*Responsible for review appeals relating to technical and clinical issues identified during the billing of claimsWork with HIM and facility clinicians to correct deficiencies in a timely manner*Review and Identify problem accounts and trends. Escalate as appropriateProperly document patient accounts with actions taken to resolve issue, as well as resources used.*Maintain communication with insurance companies to secure payment on account balances outstanding, via letters or phone calls*Assist with any other task or assigned duties as requested from manager or team leadGrievance and Appeals Analyst Senior / Anthem of VirginiaReview, analyze and process non-complex grievances and appeals in accordance with external accreditation and regulatoryrequirements, internal policies and claims events requiring adaptation of written response in clear, understandable languageUtilize guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for reviewStrictly follow department guidelines and tools to conduct reviewsEnsure the file review components of the URAC and accreditations are must pass items to achieve the accreditationAnalyze and render determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determinationUtilize medical management review activities which require the interpretation of clinical informationServe as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departmentsLead multidisciplinary, continuous quality improvement program to improve patient outcomesUpload company procedures and policies to EDMS, routing for approval and trainingAssist BOI offices with business development and customer serviceAssist manager of appeals with new hire processing and existing training programsCollaborate with different departments and levels of management to gain consensus on procedural documentationMonitor number of cases received and returned by employees on weekly, monthly and quarterly basisJan 2013 April 2018Richmond, VACustomer Care Representative III / Anthem of VirginiaAssisted Manager with administrative and project management tasksAssisted team members by demonstrating key features in MCW, AIMS, Outlook, POS and Microsoft WordReceived inbound calls from both members and providersResolved issues for members, providers, group administrators and brokersAnalyzed the situation and completes research to ensure no rework or follow-up issuesApplied knowledge of policies and procedures, products, legislation and claims, customer service workflowInteracted with systems to ensure, policies are current, and active, provide information on deductibles, coins, benefits to date, claims are paid or denied based on terms of contractInitiated interaction with other areas to ensure claims, appeals, billing issues are submitted properly and thoroughlyPerformed other duties as assigned. Mentor incoming new hires, with additional one on one training on daily functions of departmentReduced/updated/ resolved team aged inventory 30+ daily/ Review/ route provider Reconsideration (151) request. Review/ route provider/ member AppelsStop pay-Reissue check request for both member and Providers Jan 2007 - Jan 2013Richmond, VAOffice Service Coordinator / Virginia Oral and Facial Surgery Delivered quality and compassionate care to every patient Greeted all patients upon arrival or departure*Ensured parents who are waiting are kept informed of the progress of their appointment or status*Maintained a clean and tidy waiting area and front desk area*Verified insurance eligibility prior to appointment and ensured all patient information is correct in the patient's charts*Coordinated with Clinical Team Leader and Doctors to provide the opportunity for same day care to patients*Assisted with meeting office financial targets by ensuring the hygiene and operative schedules are full*Scheduled follow-up operatory and six month recall appointments for patients*Answered incoming calls and direct the caller to the proper person, taking messages when necessary*Ensured patients were receiving the dental care they need by making outbound calls to confirm patients, to reschedule patients that do not make their appointment, and to call patients that have treatment that is unfinished/ incomplete*Ensure all patient records are re-filed at the end of the day*Totaled out daily counts with record keeping to the business office EDUCATIONNorfolk, Virginia Associates in Nursing Administration Norfolk State UniversityGPA: 4.6Washington, DC High School DiplomaPaul Laurence Dunbar H.S.GPA: 3.7 |
