Director of Clinical Revenue Resume

SUMMARY:

My goal is to become associated with a Healthcare Facility where I can utilize my skills and enhancing the company's Productivity, Cash and improve their overall Revenue Cycle performance.

SKILLS & ABILITIES:

Experience with Denial Management and appeals at Confidential and State levels.
Understand HIPAA compliance, FDCPA laws, state/ Confidential guidelines for billing/collections as they relate to health care providers.
Understanding of 5010 compliances, 837I and 837P formats for electronic claim submissions as well as CMS 1500 and UB04 paper claim specifications

PROFESSIONAL EXPERIENCE:

Director of Clinical Revenue

Confidential

Responsibilities:

Responsible for the monitoring and analyzing all governmental requests.
Including but not limited to ADR’s, CERT’s, RAC’s, ZPIC’s and SMRC’s.
This also includes the CMS Based Audits: MAC, PSC, MIC and OIG. Served as an Mediator, Arbitrator, Referee and Private Judge combined with superior case management to assist clients thru the processes.
Managed staff in the day - to-day tasks and responsibilities of auditing and provided training in developing responses.
Identifies the need for changes in policies, procedures, documentation strategies and protocols based on State and Confidential regulatory requirements and make recommendations as indicated. Identifies the need for new and revised policies and training based on trends, changes in regulations, operations or clinical programs.
Review and analyze claim denials to perform the appropriate appeals necessary for reimbursement.
Receives denied claims and researches appropriate appeal steps.
Communicates directly with the payor, resubmits denied claims, underpaid claims and claims that are inaccurately processed by auditing accounts to check on proper payments, coding, balances, adjustments, etc. and using appropriate reports and working queues.
Tracks and documents all denials by payor, visit type and denial category. Identifies, documents, and communicates trends in recurring denials and recommends process improvements or system edits to eliminate future denials Under the direction of leadership works with necessary departments (e.g., Case Management, Medical Records, Patient Access, PFS Resolution Team, etc.) to drive process improvement and system edits.
Works with the payors to understand specific reasons for denials and preventable measures available to prohibit future denials.

Confidential, GA

Advance Denial Specialist

Responsibilities:

Responsible for responding to, managing and monitoring all payer requests for additional documentation ADR, appeals and denials.
Works with staff and managers to gather required information and ensure timely response to payer.
Responsible for constructing response to denials and appeals, utilizing any Confidential guidelines or local coverage determination guidelines that are applicable to the record and response.
Provides trended reports for operations and clinical management to improve performance, collaborates with and acts as a resource for division and support staff in identifying areas in need of attention/improvement.

Confidential, CO

Travel Consulting Services Director

Responsibilities:

Partner with clinical team on denials related to authorizations.
Reviewed records and operations as required regarding compliance with policy and payer requirements.
Responsible for monitoring the Confidential from Government Payers.
Provided 30 day timely response to all MAC demand letters.
Provided updated reports to clients to decide on Options to request immediate recoupment or an Extended Repayment Schedule ( Confidential ).
Submitted a rebuttal to the MAC within 15 calendar days from the date of a demand letter if warranted.
Responsible for timely responses to IRL 60 - 90 days after the initial demand letter. Track and document claim denial trends by insurance payer and review and approve Adjustment/Refund requests. Trained, monitored the Credit Balance department and EOB Posting Teams.

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