Accomplished healthcare management professional who proudly maintains a highly productive, efficient, and results driven environment at all times.
- Excellent oral and written communication skills
- Extensive experience with project planning, execution, monitoring, and resource management
- Knowledge of HIPAA, Federal, and State statutes and regulations
- Medicaid Management Information Systems and Medicaid policy
- Skilled in using structured techniques for documentation, analysis, evaluation, and decomposition of high level data
- Extensive knowledge of ICD - 9, ICD-10, CPT coding, HCPCS coding, UB-04 and CMS-1500 medical billing.
- Extensive knowledgebase in enhanced outpatient mental health services.
Medical Claims Processing Manager
- Manage, direct, and monitor personnel in activities supporting the operation and maintenance of Central Bill Processing (CBP) programs for the Office of Workers Compensation Program to include FECA, Black Lung, and Energy.
- Responsible for medical bill intake, authorization processing, and call center operations.
- Hire and terminate employees and make operational decisions that have financial impact.
- Define workflow and work processes to ensure timely compliance with SLA’s for federal contract.
- Manage, direct, and support over 40 employees in accurate medical bill processing.
- Responsible for ensuring bill processing timeliness to support service level agreement requirements.
- Provided project management leadership and enterprise account level management in a customer facing role
- Formulate policy and procedure guidelines for medial bill processing for various medical provider types.
- Served as project lead on re-enrollment and credentialing implementation for current OWCP providers.
- Formulate customer service reports (CSR) and define business requirements (BR) for claims system updates/changes for internal and external client use.
Confidential, Raleigh,North Carolina
- Audits processed behavioral health claims for accuracy in adjudication against Medicaid/IPRS schedule of benefits and payment based on various sampling methods; providing feedback to adjudicators for corrections
- Tracks and trends audit results, providing feedback to management and recommend quality improvement measures.
- Generate monthly reports to the claims examiners documenting overall statistical and financial errors.
- Identifies and reports on systemic issues which create ongoing quality concerns.
- Review Provider Audit appeals impacted by edit triggers or internal audit projects.
- Provide timely resolution and accurately document decisions and actions in tracking system.
- Assist with selection of audit criteria based on historical findings or new coding rules.
Confidential, Raleigh, North Carolina
- Performing EDI analysis, documentation, research, and testing of transactional data of 276, 277, 834, 835, and 837 for IPRS and NC Medicaid programs.
- Create documents based on specifications analysis of rules from both incoming and outgoing EDI transactions
- Research, document, and troubleshoot provider claim information.
- Provide technical support to Local Management Entities (LME) throughout North Carolina.
- Develops test data and executes test plans to ensure the system operates as defined.
- Extensive knowledge of healthcare billing/Medicaid MMIS claims processing, claims research.
- Extensive knowledge of claims processing for Medicare and Medicaid for various insurance carriers and provider types. Currently pursuing RHIT certification.
Confidential, Fayetteville, North Carolina
Medical Office Manager
- Created and maintained computerized record management systems to record and process data and generate reports.
- Managed and directed fiscal operations, including planning budgets, authorized expenditures, accounting, established service rates and coordinated financial reporting.
- Initiated audit process to evaluate thoroughness of documentation and maintenance of facility standards. Electronic claims processing of CMS 1500, UB-04, claims auditing, and EHR.
- Supervision of patient scheduling, registration, financial counseling, medical records, billing and collection, data entry and processing, cost reports and cash posting.
Confidential, Fayetteville, North Carolina
Director of Operations Medical Office Manager
- Over 10 years’ experience as Director of Operations of medical claims processing firm specializing in medical office set up and management.
- As Director of Operations, administered profit and loss, undertook all facets of decision making, strategically guided agency operations and productivity, and assumed complete responsibility for revenue performance.
- Assisted Medicaid and Medicare providers in medical office set up, management, and medical billing training for office staff.
- Conducted HIPAA compliance seminars for medical providers.
- Contract Management, credentialing, provider enrollment, QA/QI functions.
- Conduct claims processing functions for Medicare, Medicaid, BCBS, and Tricare etc.
- Provide audit functions for denied claims, claim recoupment’s, and reduced payment errors.
- Extensive knowledge of ICD-9, CPT, and HCPC’s coding and claim auditing.