SUMMARY OF QUALIFICATIONS:

• Over 10 years of experience in the medical field with a heavy focus on Medical Billing Management, Medical Coding including ICD-10, claim submissions including EDI transactions 837/835, 276/277, 270/271 collections follow ups and HIPAA laws.
• Strong interpersonal and communication skills at all organization levels.
• Proficiency with Medical Manager, SSI, ePremis, Epic, AS400, CPSI, NTT, McKesson, Emdeon, and Allscripts.
• Reliable and flexible team player with strong leadership, critical thinking and research skills
• Knowledge in HIPPA compliance, Centers for Medicare Medicaid Services CMS guidelines, General Accounting Acceptance Principle GAAP , Statement on Auditing Standards SAS , General Accepted Auditing Standards GAAS and Sarbanes Oxley Act SOX .
• Focused, detail oriented and a self starter. Extremely organized with the ability to prioritize and meet deadlines.
• Experience using SQL.
• Extensive experience and knowledge with Medicare and/or Medicaid inpatient and outpatient reimbursement including DRG and EAPG reimbursement.

PROFESSIONAL EXPERIENCE:

Confidential

Billed for LTC Medi-Cal.

• Check Medi-Cal eligibility monthly and update in NTT.
• Verify Medicare eligibility and number of covered days remaining.
• Configure charge import file for importing into NTT.
• Import, process and validate charge import file in NTT monthly.
• Create, upload and submit Medi-Cal claim file monthly.
• Enter Medicare Part A B claims into DDE.
• Print hardcopy HMO and commercial claims and mail.
• F/U on status of Medi-Cal, Medicare, and Commercial claims.
• File appeals on denied claims.
• Create, print and mail patient statements monthly.
• Financial counseling with resident's families.
• Work with patient's families and State caseworkers to obtain LTC Medi-cal for eligible patients and to have patient's coverage transferred from other counties.
• Research and post non covered and other denial adjustments into NTT.
• Research and posts refunds in NTT.
• Complete eTars for Medi-Cal.
• Enter Default Reimbursement tables into NTT for new residents. Build new payer/plans in NTT.
• Work pre close error report bi monthly in NTT and resolve any issues including MDS missing, reimbursement table errors and AR posting errors.
• Complete month end in NTT.
• Work Aging AR reports in NTT to keep accounts current and identify any insurance denial trends.
• Educate and provide staff with Medi-Cal admission and discharge documents and instructions on where and when to send documents to Medi-Cal and the SSA field office to remain compliant with state regulations.
• Code new admissions records and enter codes into NTT.
• Implemented ABN process for SNF and trained staff on workflow and regulations for issuing ABN.

Confidential

Medical Coder/Biller

• Responsible for HCPCS, CPT and ICD-9 coding all patients' records.
• Held weekly team meetings with the billing team giving them to resolve any billing issues involving modifiers or other denial reasons.
• Obtaining pre authorizations from governmental and commercial insurances.
• Entering charges into Emdeon.
• Resolving edits, rejections, hold and suspended claims in Emdeon.
• Working AR Aging Reports to keep accounts current.
• Resolving credit balances on accounts by issuing refunds, correcting contractual adjustment posting errors and working with insurance payers on recoupments.
• Posting all electronic and manual insurance and patient payments.

Confidential

Billing Team Lead

• Responsible for monitoring workloads for 9 Billing Specialists that represent numerous facilities
• Held weekly team meetings with the secondary Medicaid team giving them focus for their workload, while resolving any billing issues that may arise
• Coordinated billing activities to assure that standards are adhered to and that the electronic filing process functions efficiently and accurately
• Motivated the team to bring their average of 250 daily errors down to zero
• Tracked High dollar accounts for all facilities
• Provided training and education to billing staff as well as on site vendors on billing procedures
• Researched and maintain the EDI rejection file for Medicaid, as well as commercial, making corrections to claims for resubmission
• Completed a weekly report for the Billing Director for unbilled claims and re-bills
• Monitored team with daily emails to inform them of their progress and where they need to be at the end of their work day and assist them in obtaining their goal
• Assisted and trained on SSI edits and submit SSR's when necessary to add or remove edits for proper electronic and hardcopy billing
• Created processes for the billing department and placed on the department shared drive
• Reviewed and assured the quality of work for each secondary Medicaid biller on 5 accounts per pay period
• Maintained billing for 4 hospitals on my own, as well as all of my team lead requirements
• Have worked beyond my required productivity rate for the Team Lead at 174 with a quality assurance of 100

Confidential

Project Manager

• Trained new employees and provided updated policy materials to all employees.
• Managed the passwords for all systems as well as all web portals and implemented a policy for Check In and monitored the process.
• Served as the administrator for GRITS Georgia Registry of Immunization Transactions and Services , GBHC Georgia Better Health Care , GHP Georgia Health Partners and Tri-Care
• Served as the HIPAA officer for 2 years of my employment.
• Billed all claims that were entered and conducted insurance follow up for all private insurance, government payers and self pay patients.
• Managed private pay balances as well as maintained accounts through the Credit bureau when necessary.
• Maintained Medical Manager System and updated when necessary.
• Maintained a collection average above 90 with insurance and private pay combined.
• Billed for several different state Medicaid programs.
• Served as a super-user for several states including but not limited to: Alabama, Georgia GHP, MMIS web portals , Nevada, and California.
• Billed out of state Medicaid programs for Florida, Mississippi, Utah, and Washington.
• Proficient in all HCA data systems required for my position including SSI, Synergy, Host, MDX, DEI, and Artiva, as well as all web portals required for state Medicaid billing.
• Worked well above my required productivity at a rate of approximately 200 with a quality assurance average of 99 .

Confidential

Healthcare Consultant

• Medical coding for profit stability and facilitate any coding changes to maximize revenue.
• Responsible for evaluating the coding practices of providers evaluating accuracy providing recommendations for compliance and coding support.
• Facilitate strategic goals and ethical standards, assess and implement long-term and short-term goals financially using insurance carrier's guidelines and standards.
• Work as an interim manager directing health information management functions of the business office.
• Ensure compliance with federal and state laws, regulations correlating coding principles.
• Accurate coding and abstracting of medical records data, electronically and manually.
• Monitor health information procedures ensuring high quality standards of documentation, ethical practice, confidentiality, information security, information retention and retrieval.
• Researching and analyzing UB claims interpreting reason for denials, referencing policies.
• Identifying and implementing coding opportunities for enhanced reimbursement.
• Trained staff on A/R collections for maximum efficiency of reimbursement.
• Implemented a denial management policy and procedure to handle claim denials/rejections and establish an appeals process.
• Tracked aging and denial trends.