SUMMARY:

10+ years in the health insurance industry; proven success leading teams, projects, and lean business practices to improve efficiency, increase revenue, and reduce operating costs. Key stakeholder of a collaborative multi - year project to design, build, implement, and maintain an Epic EMR used across inpatient facility, outpatient clinic, and community-based healthcare settings. Solid reputation for professionalism with healthcare providers, private and Medicaid carriers, and employee relations.

STRENGTHS INCLUDE:

• Extensive background supervising, managing, and training healthcare industry professionals.
• Highly skilled at creating systems, processes, and workflows for all revenue cycle functions, specializing in medical/behavioral claims and group home billing through Oregon state payment system eXPRS.
• Fluent knowledge of relational databases, database normalization, Epic processes/workflows, modular integration, and system configuration for professional billing, hospital billing, scheduling, registration and SQL-based reporting (My Reports, Reporting Workbench, and SAP/Webi).
• Proven ability to troubleshoot EMR systems and translate technical jargon into discernable language for non-technical people to understand; familiar with many systems including Epic, CareLogic, Centricity, and Therap.

CORE COMPETENCIES:

Inpatient/Outpatient Billing | Medical Coding | Claims/Payments | EMR Systems | Staff Training | SharePoint

Process Improvement | MS Excel/Access | Financial Reporting/Analysis | HIPAA | HIT | Systems Analysis

Medicare/Medicaid Reimbursement | Financial Report Design/Execution | Provider/Facility Contracting

Lean Methodologies | Physician/Provider Relations | Team Leadership | Documentation

PROFESSIONAL EXPERIENCE:

Confidential, Portland, OR

Revenue Cycle Manager

Responsibilities:

• Led the revenue cycle design, user acceptance testing, and multi-phase implementation of a “universal EMR” (Epic) agency-wide.
• Transitioned agency from paper claims, remittances, and checks to electronic transactions via 835, 837 file submissions, EFT/ACH payments, and card readers. Eliminated 99% of all paper with electronic document control, reducing overall administrative costs significantly.
• Rebuilt outgoing EHR system to allow EDI transactions; reduced overall AR days from . Never lost an administrative appeal or reduced payment for any hospital claim.
• Performed case rate billing and capitation analysis to ensure maximum reimbursement, avoiding costly paybacks to Kaiser Permanente NW, HealthShare, CareOregon, and FamilyCare.
• Created a database for >10,000 ODDS monthly transactions totaling $700,000 in monthly charges; automated payment posting process, eliminating the need for time-consuming manual posting via Excel spreadsheet.
• Helped create and implement agency work-from-home policy.
• Designed all system financial reporting and performed month-end close process; provide accurate monthly financial reporting to all departments.
• Reviewed all private and Medicaid carrier contracts to match claims submitted with appropriate place and reimbursements.

Confidential, Portland, OR

Business Systems Analyst

Responsibilities:

• Provided primary support to entire agency for issues related to provider management databases and Provider Information Management System PIMS ), allowing prompt, contractually accurate claims payment for >20,000 claims daily.
• Managed/maintained all user provisioning requests for provider management database via SharePoint Helpdesk.
• Designed and executed SQL queries to provider databases for recredentialing applications, fee schedule changes, provider/facility contract revisions and notification of administrative/medical policy changes.

Appeals Specialist

Confidential

Responsibilities:

• Reviewed claim coding and claim processing history, medical and reimbursement policies, regulatory and legal requirements, benefit contracts, marketing and enrollment material, and provider contracts to make appeal determinations and communicate decisions.
• Facilitated clinical review panels with nurses and physicians; presented complex cases to internal and external appeals panels.
• Designed, tested, and trained staff to utilize an on-demand SQL query that displayed authorization claim payment logic, eliminating manual processes that required additional labor costs to maintain.
• Provided accurate and technically complex or simplified, professional documentation, education, and assistance to members, providers, and other departments regarding benefits, claims payment, eligibility and determinations.
• Gained a thorough understanding of end-to-end processes between utilization, case management and the interaction of utilization management and claims payment database. Received, researched, and assisted with written inquiries and telephone calls related to preauthorization and case management requests. Priced, researched and processed high-dollar and technically complex claims.
• Developed, documented and deployed training on products, systems, and processes to staff.
• Analyzed departmental workflows and processes and identified opportunities for improvement.

Confidential, Romulus, MI

Chief Administrative Officer

Responsibilities:

• Trained staff on all new business software.
• Processed all accounts payable/receivables, payroll, and daily bank deposits.
• Implemented effective methods of account management via electronic document control.
• Reviewed all vendor contracts and negotiated lowest possible costs.
• Designed new computer network; purchased and installed all computers and network equipment.