Medical Claims Compliance Auditor at ERN Enterprises, Inc (2019-01 – Present)
- Conduct case review of unresolved cases via client remote to determine denial reason and noncompliance code(s).
- Research denied claims through the use of EOBs received from insurance carriers.
- Locate laws that support provider appeal position.
- Clinical Chart Reviewer/Acute care setting: inpatient and outpatient.
- Make compliance calls to payors and regulatory agencies.
- Write regulatory appeal letters and demands.
- Work collaboratively on projects.
- Auditing other coder's work or helping them with any questions.
- Follow up on the daily auditing activities on assigned cases as well as outstanding insurance claims submitted to carriers, including phone calls to insurance for claims payment compliance, appealing claims, and additional functions to bring the case to closure.
- Keep abreast of compliance regulations, standards and directives regarding governmental/regulatory agencies and/or third-party payors.
- File regulatory complaints.
Medical Review Coordinator at Considine & Associates, Inc (2017-12 – 2018-02)
- Coordinated Medical Reviews to determine the medical necessity of procedures based on clinical documentation and/or to determine if procedures are considered to be experimental and/or investigational
- Managed review of cases for benefit coverage determinations, surgical predetermination, length of stay, level of care, appeals reviews, quality of care, and for appropriate coding and pricing.
- Coordinated send outs for medical reviews to board certified specialist physicians
- Determined appropriate coding of claims and medical necessity for procedures performed as well as proposed predetermination requests.
- Assigned medical reviews on initial and appeal levels and for peer to peer discussions between consultants and providers
- Completed reports and communicated the findings and determinations to our clients.
- Follow up with clients to ensure prompt and timely response to answering client questions and requests for information.
- Experience with wide range of cases including medical, dental, psychology, disability, and workers' compensation.
AR Specialist / Medical Collector Supervisor at CHMB Inc (2017-05 – 2017-11)
- Strong customer service skills; answering client, patient and carrier calls; prompt return and follow up to all interactions; prompt response to requests for information
- Timely management of unpaid claims as assigned, through the use of the client's office manager; aging reports; correspondence; Clearinghouse and PM rejections; SharePoint
- Effectively handle complex payer denials; responsible to ensure that secondary claims are sent and paid
- Monitoring and reconciliation of claims
- Denial trends
- Manage and track information requests to client.
- Answer and resolve all incoming calls and requests in a timely manner.
- Complies and enforces and policies and procedures
Medical Claims Compliance Auditor at ERN Enterprises, Inc (2015-07 – 2017-04)
- Conduct case review of unresolved cases via client remote to determine denial reason and noncompliance code(s).
- Research denied claims through the use of EOBs received from insurance carriers.
- Locate laws that support provider appeal position.
- Clinical Chart Reviewer/Acute care setting: inpatient and outpatient.
- Make compliance calls to payors and regulatory agencies.
- Write regulatory appeal letters and demands.
- Work collaboratively on projects.
- Auditing other coder's work or helping them with any questions.
- Follow up on the daily auditing activities on assigned cases as well as outstanding insurance claims submitted to carriers, including phone calls to insurance for claims payment compliance, appealing claims, and additional functions to bring the case to closure.
- Keep abreast of compliance regulations, standards and directives regarding governmental/regulatory agencies and/or third-party payors.
- File regulatory complaints.
