JeseNka Ratkovic

Perform complex retrospective review of medical records to identify potential abuse and fraud, and inappropriate billing practices. Responsible for second level appeals reviews.

Special Investigation Units (SIU) Clinical Investigator II - wellcare/Centene

(2018-04)

Perform complex retrospective review of medical records to identify potential abuse and fraud, and inappropriate billing practices. Responsible for second level appeals reviews.

• Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing code, regulatory and state guidelines, and policies
• Prepare summary of findings and recommend the next steps for providers
• Identify preventative measures and recommend changes to internal policies and procedures to prevent future fraudulent and erroneous practices
• Consult Investigators to identify abuse and fraud by utilizing coding expertise
• Assisting with provider education and answering questions from Investigators and providers
• Answering questions from Clinical Investigator I employees
• Auditing work of junior-level employees and mentoring/training new employees
• Working with Investigator on preliminary cases for final approval
• Lead for work group called preliminary collaboration with creation of SOP (Standard Operating Procedures) for preliminary collaboration process

Trainer, Compliance & Coding Auditor - Medent Inc

(2017-08 - 2018-04)

Responsible for all the training in the AR & Billing/Coding department that consists of an offshore team. Managing offshore teams for coding, charge entry, payment posting and AR.

• Auditing staff performance in coding, data entry, billing, payment posting and AR
• Continually researching billing and reimbursement guidelines for government and commercial payers as well as coding updates
• Areas of expertise include but not limited to operative report audits, compliance manuals, software training, coding software, payer websites, and compliance training

CBO (Central Business office) process analyst, Trainer, Compliance and Coding Auditor - Intralign Inc

(2004-11 - 2017-08)

Responsible for all the training in the AR & Billing/Coding department that consists of on-shore and off-shore teams along with the creation/development of standard work, compliance manuals, flow charts, company policies, billing policies, and procedures. Managing offshore teams for coding, charge entry, payment posting and AR.

• Auditing staff performance in coding, data entry, billing, payment posting, and AR
• Continually researching billing and reimbursement guidelines for government and commercial payers as well as coding updates
• Conducting an on-going analysis of processes within the AR & Billing department
• Areas of expertise include but not limited to operative report audits, compliance manuals, software training, coding software, payer websites, and compliance training
• Interim Team Lead for AR Team that consists of staff responsible for the collection of payment and payment posting from the government and commercial insurances (November 2013-March 2014)

AR Appeals/Credentialing/Audits/Compliance - Bonati Spinal Institute

(2004-11 - 2011-04)

• Developed appeals for specific denials
• Assisted Business office Manager in coding and compliance research
• Held compliance orientation for new employees
• Managed credentialing of all physicians

AHFI - Accredited health care fraud investigator - NHCAA (national Healthcare Anti-fraud Association) (2021-10)

CPMA - Certified professional medical auditor - AAPC (2019)

CPC - Certified professional Coder - AAPC (2004)

Diploma - Medical billing and coding specialist - Education direct Aka pen foster (2002)