SUMMARY

Strong Healthcare Insurance Coding Professional with in - depth experience in all aspects of regulatory compliance and processing. Demonstrated ability to maximize providers’ reimbursements through accurate interpretation of contracts, detailed familiarity with coding definitions and ability to select correct codes to eliminate resubmissions. Possess excellent combination of academic, business and healthcare experience. Proven understanding of the need to provide high levels of customer service.

Configuration/Implementation

• HIPAA Medicare Medicaid Private Carriers Certified Professional Coder NCCI
• Problem Resolution Customer Service Accounts Receivable Collections Leader
• Provider/Insurance Experience Contract Interpretation Trainer/Mentor

Software: RMI, DMS, Notes, Business Object, BLAPP, FIAGRO, CIS, CIT, ICD - 9, CPT Coding, CMS 1500, UB-92, HIPAA Regulations, EDI, MMIS, Amysis, Emptoris, Service Now, Meditech, IDX, Claims Logic, Health Quest, Proxy Med, Web MD, Microsoft Office Suite; Ecommerce and Medical Terminology and other software programs

PROFESSIONAL EXPERIENCE:

Confidential, Atlanta, GA

Medical Coding and Billing Supervisor

Healthcare organization specializing in small physician practices in the area of Revenue Cycle Management, Policy development, Financial analysis, A/R audits and Medical Coding to optimize reimbursement; provide efficient & productive staff; as well as organize or streamline systems.

• Supervised a team of 7 for front and back office staff, billing and medical coding.
• Education/training of CCI Edits, Modifiers, to optimize reimbursement.
• Review revenue cycle.
• Project Management (varied types).
• Compliance& HIPAA Program Development & Implementation.
• On-boarding specialist - responsible for providing training and education sessions to healthcare providers and staff on Correct Coding, Billing, CMS guidelines and TRS’ Medical Policies.
• Provide leadership changing business processes and payment policies and system configurations driven by changes in regulatory requirements and compliance responsibility for claims processing in the Southeast region.

Confidential, Atlanta, GA

Quality Assurance Tester

Ensure current Edits and Audits are applicable for ICD 10 Diagnosis codes and ICD-10-Procedure Coding System (ICD-10-PCS) PCS Codes. Work closely with Medical Policy and Business Analysis teams to develop/validate test scripts, manual and automation. Understand detailed technical and business requirements. Execute manual and automated test script. Log and manage bugs/performance issues with Development team.

• Performing and Validating Test Cases.
• Retesting in support of defect remediation.
• Reporting defects and performance results.
• Coordinating test data creation (and system refreshes).
• Verified patient’s eligibility and benefits via EDI.
• Reviewed Remittance advice via EDI.
• Verified and reviewed claim submittal via EDI.

Confidential Smyrna, GA

Lead Implementation Analyst

Ensured Centene s configuration is correct base on state manuals and provider contracts. Provider support based on provider s contract and claim adjudication questions. Verified members eligibility using MMIS. Work with provider relations representative to ensure correct configuration according to provider contract and State requirements. Acquire and stay current on latest regulations issued by DCH ( Confidential ). Issue regular progress/status reports to management.

• Ensure accurate contract implementation and subsequent claims processing through provider setup, UAT testing, etc. on basic Change Requests (CRs) (i.e.RHCs/FQHCs/fee schedule updates).
• Verified patient’s eligibility and benefits via EDI.
• Reviewed Remittance advice via EDI.
• Verified and reviewed claim submittal via EDI.
• Troubleshoot and problem solve contract implementation issues related to basic Amisys configuration
• Review contracts and assign pay classes and applicable provider information based on contract language.
• If configuration is needed to accommodate a contract, notify the appropriate parties.
• Assist with the internal communication of all new and revised material contract terms and provisions to all affected departments.
• Review new and current provider contracts and established state guidelines.
• Participate in determining the appropriate configuration of the claims payment process in the appropriate subsystem of the claims payment information system in conjunction with health plan, claims and corporate management and information systems staff.
• Responsible for running weekly and monthly reports regarding providers pay classes and edits via business object.

Confidential Atlanta, Georgia

Policy Configuration Analyst

Responsible for processing Rule Maintenance Requests (RMRs) and configuring the rules associated with them for each release by the Configuration Cut deadline. Responsible for testing Medical Polices to ensure product integrity, accuracy and quality by the Quality Assurance deadline.

• Processed RMRs to create new rules and new rule versions associated with Library and Custom rules using the Rules Maintenance Interface (RMI).
• Processed RMRs to modify existing rule versions to ensure rules for iHT clients are configured in accordance with the rule descriptions and instructions on each request.
• Processed RMRs in a timely manner ensuring each request is completed by the end of business on the Configuration Cut deadline reflected on the Release Schedule.
• Responsible for actively monitoring the Configuration queues in the RMR database to ensure all requests are processed for the appropriate Release Month.
• Performed Peer Review responsibilities by reviewing rules associated with RMRs processed by other Configuration and Testing Analysts. This responsibility includes specifically identifying issues associated with the configuration, switches, or editorial fields of the rule or RMR being reviewed.
• Configured rules in accordance with rule configuration guidelines contained in the appropriate Team room or Process Guidelines reflected in the Document Management System (DMS).
• Documented actions taken for each RMR in the appropriate field of the RMR.
• Responsible for QA for each rule associated with RMRs processed. This includes running QA for each RMR reviewed when performing Peer Review responsibilities.
• Developed test scenarios to thoroughly test medical policies (Temp Rules, Switch Requests, Change Requests, and Research Requests).
• Researched internal requests to resolution.
• Analyzed and troubleshoot erroneous results, determined the root causes and suggested a solution.
• Communicated effectively and timely with upstream functional areas to resolve issues.
• Maintained the following accuracy target in reference to testing rules - minimal error rate of 3 or less (Critical Omissions) per quarter.
• Conducted Regression Testing of medical polices to ensure client specific medical policy accuracy and quality.
• Evaluated Pre/Post test results of client files for accuracy and quality.
• Responsible for meeting daily and monthly production and quality targets.
• Assisted with Research Requests.
• Participating in other projects, as needed.
• Assisting in the training of newly hired Configuration and Testing Analysts through job shadowing.
• Actively participating in Rule Review efforts. This responsibility includes reviewing rules assigned to each analyst and documenting potential configuration issues on the document associated with the Rule Review effort.

Client Business Analyst

Ensure each client’s contracted reimbursement obligation for a chosen policy set has been implemented accurately based on the client’s decisions. Provide on-going client support, including ensuring the accuracy of policy configuration, supporting claim adjudication questions and maintaining documentation related to the client’s policy set. Work with assigned client (primarily Coventry Health Insurance) configuring policies to optimize cost-savings based on new rules. Acquire and stay current on latest regulations issued by CMS and individual state agencies. Issue regular progress/status reports to management.

• Acquired Coventry in 2007 as a new account; assisted with configuring over 1500 medical policies within guidelines and regulations of 19 states and federal guidelines; developed technical outline for IT portion; maintain and load client-specific data onto spreadsheets.
• Vigilantly review monthly policy activity, identifying issues and recommending changes (300-400 monthly); regularly identify, enter and maintain policy changes, notifying IT of changes.
• Ensure client is in compliance with federal, state and local insurance guidelines regarding coding and billing.
• Periodically assigned to assist with plans on other accounts, including Aetna, Blue Cross/Blue Shield, Cigna, and United Health.
• Recognized as a Subject Matter Expert (SME) for Multiple Procedure Reduction Policies; serve as escalation point for employee issue resolution, client communication and internal staffing support needs.
• Ensure client satisfaction through delivery of timely and quality services; research reports and questions received from client; manage customer expectations; resolve client issues.
• Conduct research and analysis of current market and regulations, prepare presentations, and participate in meetings delivering proposals to clients.
• Serve as mentor and trainer for new and current associates, ensuring understanding of company initiatives, processes, methodology and identify performance improvement opportunities.
• Assist the Client Team in determining which policies need to be presented to client based on client-specific rule configuration; provide input into the development of SOPs, guidelines, policies, procedures and technical/functional requirements.
• Provide ongoing evaluation/analysis of expected/projected accuracy and productivity rates for project tasks and develop processes to ensure error-free output.
• Assist in documenting the changes within the Periodic Update, which contains the policy changes for presentation to clients.
• Coordinate tasks, workload and priorities with team leads, specialists and other resources involved in projects.
• Collaborate on DM software defects and enhancements, document changes and specifications discovered through daily use, QC, and training.
• Maintain current knowledge of internal control responsibilities, participate in internal controls self-assessment process; accountable for internal control performance within area of responsibility; ensure subordinates have proper internal control training.
• Responsible for running weekly and monthly reports regarding rule sets, client sets and edits via business object.
• Promoted after 6-months, Business Analyst II with Coventry account responsibilities.

Confidential, Atlanta, Georgia

Senior Recovery Specialist

Personally processed 50 Medicare and Medicaid claims daily, while managing a group of 20 each with similar processing responsibilities. Oversaw accuracy and timeliness of billing all professional claims, working on government claims full cycle. Researched rejections and properly completed and resubmitted paperwork. Analyzed reports, used reporting tools and other resources to acquire information from the Confidential System and the different payers. Reviewed claims to ensure proper coding. Performed quarterly performance and merit reviews of staff. Extensive knowledge with CLIA certification and laboratory billing.

• Reviewed documentation in the medical record, accurately assigning appropriate diagnostic and procedural ICD-9-CM and /or CPT-4 HCPCS codes to the greatest specificity.
• Worked with contacts at physician’s practices to enhance account information accuracy.
• Ensured departments practiced high levels of customer service; involved physician offices when necessary.
• Performed audits of staff’s work to ensure compliance with regulations and standards.
• Promoted to Supervisor role, making decisions regarding patient accounts, responding to questions and forwarding information to referring physician payers, patients, and other hospital staff in an independent and appropriate manner.
• Managed all aged patient accounts for the sole purpose of collecting the highest possible amount on each billed account.
• Maintained close contact with personnel in specific specialties’ to ensure maximum and timely payment from all payers, including all primary, secondary, tertiary or any other payer, as well as any and all guarantors.
• Reduced number of outstanding Accounts Receivable by over 80% in one organization and dramatically improved days outstanding.
• Developed and implemented a manual covering denials and standardizing actions to be taken.
• Supervised all Medicare and Medicaid processing and represented department in meetings in Manager’s absence.
• Verified member eligibility and checked status of claims via MMIS.

Recovery Specialist

Analyzed reports of unbilled medical services and denied claims relating to insurance companies, Medicaid, Medicare, and managed care organizations. Performed appropriate research into sources of errors (missing/incomplete data, reasons for denials, failed or missing authorizations, diagnosis and procedure code issues or related information) and took appropriate corrective action, determining the most effective methods to facilitate prompt corrective measures. Filed claims electronically.

• Developed reports to track process improvements.
• Trained clinical and clerical staff on authorization and billing processes.
• Developed Medicare Manual for team, describing operational processes.
• Successfully followed up and collected on accounts with balances of $1500 and above.
• Acquired proficient knowledge and usage of the NCCI (Narrative Corrective Coding Initiative).

Confidential Atlanta, Georgia

Recovery Specialist

Responsible for the continued maintenance of the hospitals’ existing aging account receivables. Collected on aged accounts over 180 days. Reviewed contracts of insurance carriers to ensure correct payment. Worked directly with provider relations in regards to contractual issues. Appealed denied claims; filed claims. Verified patient’s commercial insurance eligibility as well as Medicaid eligibility via MMIS.

Confidential Atlanta, Georgia

Reimbursement Coordinator

Served as a liaison between the Hospice and the patient’s family. Acquired authorization, billing, follow-up and collections for the inpatient and outpatient services. Performed financial assessment to determine patient’s eligibility for assistance. Collected on all managed care accounts. Set-up and enforced payment arrangements.

• Verified patient’s insurance eligibility; filed claims.
• Designed and implemented incentive program.
• Worked with provider relations staff and case managers at the insurance carriers to ensure quality care for the patients.