SKILLS: MS Excel, MS Word,Access, Accounts Receivable, Balance Sheet, Office Procedures, Basic Anatomy/Physiology, BMR Claims, Collections/Billing, Customer Service, Ca - Citrix/, Data entry, DME, Emdeon, Era,Edi ICD9 & CPT Coding, Isuite, Lotus 1,2,3, MDX Media.com, Medi-Cal, Medical Terminology, Medicare/ CMS, Medisoft,, EPIC/ Z-CAP, Oracle PPO/ HMO, SIS/ Confidential, Macess/ Facets, Cisco WebEx, Cisco AnyConnect, RSA Token

EMPLOYMENT:

Confidential

Responsibilities:

• Price and develop/ Audit - Veteran Administration (VA) claims for missing information in accordance with VA regulations and guidelines.
• Analyze claims to be determine if all claims filing requirements have been met.
• Update line items to complete adjudication of claims.
• Analyze claims to determine Pricing and claim filing requirements are met and make determinations.
• Maintain integrity of claim auditing system by identifying and reporting potential system problems.
• Provide examples and documentation to support findings.
• Initiate written communication via web application letter writing system.
• Troubleshooting claims with potential third-party liability, and stop loss claims / potential stop loss files.
• Approving, Pending, or Pricing according to the accepted coverage guidelines.
• Perform data entry into Claims management software and other Microsoft applications-(Access, Excel)

Confidential

Claims Processor

Responsibilities:

• Analyze, Audit, pay/review and adjudicate health insurance claims.
• Process claims for inpatient, outpatient facility and professional services, Workers compensation, Behavioral Health, Etc.
• Verify member eligibility, benefit coverage and researching or applying authorizations
• Review and approve the claims/pay.
• Perform data entry, verifying client information, processing credit reports and financial documentation
• Obtain and authorization signatures on necessary documents
• Review supporting documentation for approval process and payments
• Perform research, data entry, process and or adjust health care claims using a variety of healthcare related systems
• Strong understanding of benefits and healthcare terminology.
• Encounter both standard and non - standard Medical Claims
• Verifying patient account, authorization information; analyze the information to determine payment amount or denial of payment.
• . Examine claims and calculate reimbursement based on contract terms to determine accuracy of payment along with supporting documentation.
• . Handled 115-180 accounts per day

Confidential, Fountain Valley, CA

Patient Account Representative

Responsibilities:

• Processes health insurance claims and medical payments for clients. Assists in the client appeals process.
• Identifies, researches, resolves claim issues, and requests for additional documentation where needed.
• Ensures payment processing timeliness and accuracy are met.
• Creates and updates financial batch records for processing by accounting.
• Obtaining, verifying and documenting all claim and insurance benefit information
• Submitting accurate/clean claims to insurance carriers for payment, including coordinating benefits with multiple insurance carriers and protecting benefits from with any pending third - party claims.
• Reviewing claim payments for proper reimbursements; appealing underpaid or denied claims
• . Examine claims and calculate reimbursement based on contract terms to determine accuracy of payment through use of various reports and supporting documentation.
• Reviews and Reconcile outstanding claims and/or unpaid accounts
• Posts, processes, reviews, and reconciles denials for insurance claims
• Follow up with providers and insurances for missing claims information
• Strong customer service Skills committed to meet/exceed customer needs
• . Strong knowledge of managed care and hospital patient accounts

Environment: Medicare/ CMS, Medisoft, EPIC/ EZ-CAP, Edi, Oracle PPO/ HMO, SIS, Power Mhs

Confidential

Patient Accounts Healthcare Representative

Responsibilities:

• Analyze HCFA and UB - 04 claims and adjudicate according to Benefit Plan/Guidelines.
• Review/Audit, process claims, Resolution of complex and high dollar claims.
• Calculate benefits due within a designated authority level.
• Process claims for inpatient, outpatient facility and professional services, Workers compensation, Behavioral Health, Etc.
• Resolved a high volume of claims edits for all lines of business.
• Thorough understanding of authorizations, benefits, contracts, enrollment and fee schedules.
• Hospital Collection, Commercial, Government, Managed Care
• Handled 80-120 accounts per day

Environment: Medicare/ CMS, Medisoft, EZ-CAP, Edi, Oracle PPO/ HMO, Xcelys , SIS,

Confidential, San Dimas, CA

Reimbursement Healthcare Representative

Responsibilities:

• Handled account follow - up/collections on hospital accounts such as Gardena Memorial Hospital, St. Francis Medical Center, St. Vincent Medical Center, Downey Medical Center, etc.
• Followed-up on accounts from current to 80 days.
• Performed Audits of Claims Processed by the Claims Department & employees' batches.
• Accounts Receivable / Post Recovery Checks into Claims Data Base for
• Tracking & Reporting, also accounts receivable follow up.
• Reconciled all payments received from stop loss Carrier/ Maintain outstanding receivables
• Audited Capitation Deductions Provided by Numerous Health Plans and
• Submitted Pay & Chase Quarterly Reports to the Health Plan for Reimbursement
• Provided Monthly Reports to Reflect Recoupment Totals for Each Client.
• Prepared monthly and periodic reports analyzing the accounts receivable and escalates problems as necessary.
• Critical Access / Acute Care facility billing
• Assist Management with related issues to the collection and payer claims.

Confidential, Los Angeles, CA

Healthcare Collections Specialist Inpatient

Responsibilities:

• Responsible for billing/collection and follow - up related to HMO's, PPO's, Medi-Cal
• Resolved problems regarding billing and collection matters/ payers & responded to inquiries
• Followed up calls on delinquent accounts to parents/guarantors and third party payors and secured information needed to obtain payment; maintain account log with history of billing and collection activity.
• Researched and analyzed account balances, payments and adjustments to assure full payment was received and closed out account in a timely manner.
• Prepared and batched all adjustment journals, charge reversal forms and payment transfer forms for review and approval.
• Processed/ create insurance appeals and denials.

Confidential, Culver City, CA

Lead - Financial Billing Coordinator

Responsibilities:

• Created daily deposit adjustment log accounts receivable record payments according to contract, identify and track notify Secondary or Self Pay status after primary pays.
• Examined Medicare, HMO, PPO Commercial/Manage care contracts for accurate reimbursement. Audit accounts to ensure procedure / charges are coded correctly verify implants are calculated in accordance with governmental guidelines, worker s compensation carriers as well as patient and secondary payers.
• Ensured surgery center claims were accurate and the timely collections of accounts from insurance payers.
• Monitored/ post payments to accounts and verify correct payment by utilizing managed care contracts for accurate reimbursement.
• Follow up on Medicare/ Secondary payers electronic and hard copy billings.
• Daily Patient Admit, Verify Patient Insurance Coverage/Authorizations, collect co - payments/ accounts receivable.