Med Assets, Inc. - Nashville, TN February 2015- Present
Commercial Billing PAR
• Responsible for follow up of claims on daily basis to meet departmental cash goals. Submitted claims to various insurance carriers electronically. Interpreted managed care contract, Medicare and Medicaid, and Workers Compensation. Calculate allowable determine appropriateness of reimbursement and appealed claims as necessary for maximum reimbursement.
• Maintained extensive contact with insurance carriers and communicated with patients regarding out of pocket amounts/responsibility.
• Identified accounts that have been either under or over paid, issuing credit balance information either to the insurance carrier or the patient. Adhered to practices done in a professional and communicative manner, per policies and procedures, guidelines, internal control measures and established goals. Advised patient’s patient responsibility and collect via payment plans or direct.
• Accomplish towards company goals for cash collections and A/R over 90 days. Responsible for
billing/collecting under 14 days, weekly and month-end close processes, and other departmental goals. Managed the Ready to Bill queue on a daily basis; performed QA to insure accurate and timely creation of new claims. Insured submitted claims meet payer guidelines.
Worked “unworked” status with 48 hours of confirmation date and assigned appropriate status to insure proper handling by making necessary changes to reduce rejections of submitted electronic and paper claims.
• Worked and resolved claims with 24 hours to ready or next status for resolution.
Conducted billing utilizing methods for most efficient resources to secure timely payment of open claims, untouched claims for resolutions. Explained Patient Responsibilities per EOB’s
Collected and billed secondary (if applicable) in a timely manner with appropriate supporting documentation per payer specific guidelines to insure expected revenue is allowed.
Researched sites of assigned payers to bill for payer updates and shared updates as necessary.
Skills Used: Medical terminology, Medical Coding, Utilization Review, Negotiation/Collection and Research.
Community Health Systems- Franklin TN- Nov-2013- Oct-2014
ALJ Appeal Medicare Assistant
• Assist with 3rd level Administration law Judge Hearings /Appeal process. Prepared legal memorandums and assists in the preparation of timely submission of any Additional Development Requests (ADRs), Reconsideration and Administrative Law Judge (ALJ) Reviews.
• Tracked unfavorable reconsideration and separate unfavorable decision for medical staff to review record. Record and analyzed unfavorable decision and assist in writing brief of unfavorable decision to submit to RACs, FI MACs for appeal within regulatory time lines.
• Implemented corrective action to prevent further default action and strategized Medicare claims reimbursements submission. Responsible for ensuring communication and cooperation between the Centers for Medicare & Medicaid Services (CMS).
• Responsible for handling the Administrative Law Judge (ALJ) hearing notifications and coordinating activities related to reimbursements, strategic participation in ALJ hearings with medical staff. Served as the central point of contact for ALJ hearing notifications and correspondence between the Office of Medicare Hearings and Appeals (OMHA).
• Prepared hearing schedules and assist in the coordination of documentation and participant schedules. Managed multiple tasks requiring considerable prioritization, coordination, and follow up to meet regulatory requirements. Assist in discerning Medicare coverage rules and regulations for proper favorable decisions and balance competing priorities, complex claims situations of tight deadlines any other administrative assigned.
Dell/Perot Health Care - October 2009 to Nov- 2013 Nashville, TN Sr. Biller & Coder Claims Analyst
• Pro-actively managed and processed reimbursement Medicare, Medicaid claims in accordance with company standards and statutory requirements. Reviewed claims and accurately adjudicated UB-04 claims at all levels of complexity.
• Examined, and identified principal diagnosis and procedure pertinent secondary diagnoses and procedures. Collected, investigated denials of medical claims, updated and compiled new gathered information generated via investigations.
• Negotiated and settled large claims accounts through appeal process. Resolved complex medical claims escalated issues. Facilitated Medicaid/Medicare approvals/denials via status coding. Ensured proper corrections of medical claims insurance entries including; priorities orders upon initial patient interaction (Encounter) in order to bill the patient appropriately. Verified and documented patients’ insurance information provided to the billing group or after problems have been identified through denials, correspondence from insurance.
• Documented requested information from the medical record to determined valid encounters including legibility and valid signature requirements assigning diagnostic and procedural codes to patient records using ICD-9-CM and CPT/HCPCS and any other designated coding classification system in accordance with the UHDDS coding guidelines.