Healthcare Billing and Recovery Case Worker II Specialist - Performant Financial Corporation - Sunrise, FL
(2018-01)
Subject Matter Expert in GHP and NGHP responsible for assisting and leading the GHP team in correct and efficient healthcare recovery processes.
- Responsible for the QA of the GHP team cases and generation of letters to debtors based on defense/dispute reasons.
- Review account claim and other documentation to verify payment liability.
- Initiate applicable action and documentation based upon payment options, actions required if new information is identified that may change the obligation to pay, or escalation in the event of refusal to pay.
- Support internal groups or functions with interpretation of EOB (explanation of benefits), as well as development of knowledge base and understanding of key concepts and terminology in healthcare billing and claims.
- Assist and provide team members with additional training, coaching and resources as needed.
- Effectively follow scripts, guidelines and other tools provided to have professional conversations with Insurance carrier contacts.
- Point of Contact for GHP Clients, addressing and resolving any discrepancies, areas of concern, keeping clients abreast of company changes and new processes while maintaining a positive company client relationship.
- Completes and resolve special project reports with accuracy in a timely and efficient manner.
- Assists the Financial team with receipt research concerning under and over payments, responsible for the application of receivables and refunds process within the financial system.
- Network with management on creative and innovative ways to enhance departmental recovery processes.
- Follows and complies with company, CMS and departmental policies, processes and procedures.
- Consistently achieves and exceed established metrics and goals assigned while demonstrating Performant core values in performance of job duties and all interactions.
Medical Appeals Writer / Collector - Wimbledon Health Partners - Boca Raton, FL
(2016-05 - 2017-02)
- Responsible for the review of accounts and generation of appeals based on the dispute reason and contract terms for specific payor including validating dispute reason following Explanation of Benefits (EOB) review.
- Reviewed accounts to reconcile any insurance payments or patient balance discrepancies.
- Processed contractual adjustments and write offs as needed.
- Escalated payment variance trends and issues to management.
- Researched and resolved coding and provider issues.
- Responsible for maintaining knowledge of all insurance payor requirements and guidelines for reimbursement.
- Verified and processed insurance information, authorizations, claim status, medical record request, legal letters and request from state and government agencies.
- Escalated exhausted appeal efforts for resolution.
- Exceeded daily requirement of 50 accounts worked per day.
- Worked and completed assigned payor projects effectively and efficiently by assigned deadline.
- Assisted Auditing and Collections Manager with daily departmental functions.
- Networked with management on innovative approaches to the billing and collection process.
Grievance & Appeals Specialist - Conifer / Tenet Health - Boca Raton, FL
(2013-02 - 2015-04)
- Reconciliation of Inpatient and Outpatient hospital claims with commercial and government insurances both as primary and secondary carriers.
- Reviewed accounts to assure correct insurance payments and patient balances are correct. Reconcile payment account discrepancies research and resolve refunds and reimbursements.
- Processed contractual adjustments as needed.
- Verified and processed insurance information, authorizations, claim status, medical record request, legal letters and request from state and government agencies.
- Responsible for validating dispute reasons following Explanation of benefits (EOB) review, escalating payment variance trends or issues to National Insurance Center (NIC) management, and generating appeals for denied or underpaid claims.
- Coordinated with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary.
- Generated an appeal based on the dispute reason and contract terms for specific payor. This includes online reconsiderations.
- Followed specific payer guidelines for appeals submission.
- Escalated exhausted appeal efforts for resolution.
- Worked payer projects as directed.
- Researched contract terms / interpretation and compile necessary supporting documentation for appeals, terms and conditions for internet enabled Managed Care System (IMacs) adjudication issues, and referral to refund unit on over payments.
- Performed research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately.
- Escalated denial or payment variance trends to NIC leadership team for payor escalation.
AR / Billing Specialist - Solantic / Care Spot - Jacksonville, FL
(2011-09 - 2012-12)
- Responsible for the Auditing of demographic and worker's compensation billing documentation for eleven centers.
- Processed and mailed out claims for all assigned centers.
- Researched and resolved coding and provider issues during claims edit process.
- Compiled reports / spreadsheets and notify Center Managers and Market Leaders daily/weekly of those accounts in need of immediate attention.
- Networked with managers and providers regarding issues with licensure and system entry.
- Contacted insurance carriers, employers and patients regarding outstanding balances.
- Researched and reconciled payment discrepancies.
- Assisted with charge entry for assigned centers as needed.
- Reviewed and worked correspondence, process medical appeals, adjustments and refunds as needed.
- Assisted team lead with special projects.
- Networked with management on innovative approaches to the billing process.
Team Lead/ Claims Collector - Brooks Rehabilitation - Jacksonville, FL
(2007-04 - 2011-04)
- Assisted patients in timely, efficient, accurate settlement of their accounts.
- Responsible for processing of claims and explanations of benefits both primary and secondary for commercial and government insurance.
- Reviewed accounts to assure correct insurance and patient balances were correctly posted.
- Responsible for maintaining knowledge of all insurance contracts while possessing excellent knowledge of payer contracts and requirements.
- Processed medical appeals and refunds as needed. Research and resolve refunds and reimbursements.
- Researched and resolved legal letters of disputes and request for information.
- Reconciled payment account discrepancies.
- Responsible for the processing, balancing and adjustment of payments received per contracts.
- Networked with management, team leads and provider reps in identifying and resolving insurance contract / fee schedule payment issues.
- Analyzed and created accurate reports for special projects as needed.
- Handled correspondence from state and government agencies.
- Responsible for feedback concerning specific updated insurance
- Maintained below 25% of AR goal each month.
AR Specialist / Payment Poster - Per-Se Technologies - Jacksonville, FL
(2005-08 - 2007-03)
- Responsible for processing Explanation of Benefits(EOB's), posting payments and contractual adjustments per individual contracts.
- Researched and resolved refunds and reimbursements.
- Processed denials, entered and updated claim database information.
- Entered and updated patient's demographic and database information.
- Reconciled payment accounts and account for any discrepancies.
- Per the insurance correspondence, posted payments and denial information to individual accounts.
- Exceeded hourly processing requirement of 126 accounts per hour.
- Researched, resolved and resubmitted medical claims that were rejected.
- Assisted team lead with daily departmental functions.
Customer Service/Sales Associate - Citibank - Jacksonville, FL
(2001-09 - 2004-08)
- Responsible for providing excellent customer service, and accurate account information to all new and existing card members.
- Provided cardholders with information about company products and Benefits. Handled billing inquiries and charge backs.
- Responsible for the accuracy and posting of payments and adjustments
- Verified cardholder information, processing of new and account closures.
- Handled between eighty to one hundred calls per day.
- Maintained and exceeded daily and monthly sales goals.
Medical Claims Biller – Follow Up, Contract Assignment - Sheridan Health Corporation - Sunrise, FL
(2000-09 - 2001-05)
- Utilized the AS400 and Medical Manager system to process all medical.
- Correspondence from insurance companies and attorney offices.
- Properly processed insurance denials.
- Verified and entered insurance information.
- Prepared documents for worker's compensation and auto claims processing.
- Interacted with insurance companies regarding claim status.
- Request EOB's, and authorizations when needed to bill claims.
- Assisted in collection proc
