SUMMARY:

• 12 years of healthcare experience focused on claims adjudication, benefits and Medicare claims processing; work experience in insurance, investigative, health care .
• Solid knowledge of ICD - 9/CPT/DME/Pharmacy codes for the utilization of proper claims processing and adhering to HIPAA compliance regulations.
• Posses a wide knowledge of clinical and financial aspects of patient management, for patient care setting and clinical practices.
• Assist in the development and maintenance of a configuration management process to collect and catalog project deliverables.
• Continuously works to assess and improve the organizations performance by designing operational processes, monitoring performance through data, analyzing the data, implementing sustainable performance improvement, and participating in multi-disciplinary inter-departmental activities.
• Well versed with utilizing electronic medical records systems such as EPIC to perform data analysis and promote departmental performance improvement.
• Conduct technical editing and quality assurance on project and company deliverables to ensure that content is communicated clearly, concisely and effectively.
• Provides effective leadership (and teamwork) by; coordinating and integrating services within departments, for mission critical objectives.
• Conduct reviews of instructional deliverables to ensure quality, currency, congruency and consistency with company and customer standards.
• Prior experience with the Department of VA and/or other healthcare agencies.
• Review, edit and improved content written by other team members and suggest improvements. Investigate and determine legitimacy Address and Billing changes.
• Collaborate with Directors and Managers to identify key Quality Management metrics and monitor performance.
• Review departmental SOPs and desk procedures for accuracy, completeness and consistency.
• Ability to comprehend, interpret and communicate to others the complex claims, regulations and methodology regarding healthcare billing and reimbursement.
• Generate detailed reports for submission to senior management.
• Familiarity with Patient Protection Affordable Care Act (PPACA) legislation. Maintain case management system to track progression of cases.
• Proactively respond to customer needs and provide effective/quality, technical service to resolve issues and inquires.
• Excellent written/verbal communication and interpersonal skills.
• Analyzing contract documents, provider/subscriber claims history, benefits, external data banks and other documents by utilizing various computer systems and software to make a decision as to the possible existence of fraud and/or abuse.
• Knowledge, experience and exposure implementing public or private health insurance exchanges .
• Develops and conducts investigations by performing complex fraud and/or abuse theory-approach analyses and audits of financial business records, provider and subscriber medical data, claims, systems’ reports, and internal investigations as required.
• The ability to manage multiple tasks along a parallel process.
• Identify, analyze and categorize fraudulent health care claims submissions and enrollment activity.
• Experience with customer and PMO status reporting.
• Health care research and analysis skills sufficient to support payer research, healthcare policy library, and state management.
• Experience working well in high-stress teams/department.
• Ability to communicate complex technical topics to management and non-technical audiences.
• Ability to resolve associate issues effectively and efficiently.
• Critical thinking skills.
• Advising and recommending areas of program planning, business management, budget execution and program coordination.

TECHNICAL SUMMARY:

EPIC (EMR); Healthconnect (EMR); MACESS EXP; KMATE; DIAMOND; VETSNET; MS Office Suite; Lotus Notes, Excel, PowerPoint; EMR, EPM, Charting, Results Reporting, Care & Case Management, Hyperspace User Interface

EXPERIENCE:

Confidential, Rockville, MD

Quality Analyst/Data Integrity Compliance Specialist

Responsibilities:

• Actively participates in design reviews and is able to identify gaps in requirements at the design stage by probing for detailed explanation of expectations.
• Takes full ownership of projects from a quality perspective, completing work with little guidance, and ensuring all deliverables are of high quality and delivered on time.
• Has a thorough understanding of how the end user of the applications would perform their job using the application and is recognized as a product expert.
• Creates test plans, designs and executes test cases based on business and functional requirements, application experience, advanced root cause defect analysis, and expert understanding of the business.
• Utilizes a wide range of testing techniques such as functional, database validation, negative, boundary, integration, systematic or strategic approaches to combination testing as well as some code inspection needed to isolate changes to be tested.
• Performs expert risk analysis surrounding application builds, customer priorities and defect analysis. Offers design/test solutions to meet both business and quality desires.
• Applies superior time management to multi-task and prioritize work based on risk, quality expectations, timelines and customer needs.
• Provides estimates and deliver within +/- 10% of estimate given on most occasions.
• Communicates effectively and consistently to provide Team Lead and project team with overall test status, milestones, escalated risks, and estimated completion dates.
• Able to effectively delegate work and mentor to team members on QA methodologies and product knowledge in an individual or group setting.
• Adherence to company, team and department guidelines, processes, methodologies.

Environment: TheraCall, PowerPoint, Excel, Medicaid, Medicare, Managed Care

Confidential, Rockville, MD

Senior Reimbursement Counselor/Case Manager

Responsibilities:

• Gives quarterly presentations to Directors and the VP President of Confidential on the status of prescription referral program.
• Performs data reporting for the Regional Director and Program Manager on prescriptions status (approved, not approved).
• Utilizes proprietary system (TheraCall) to document patient data used for pharmaceutical claims processing.
• Functions as the liaison between vendors, Physician offices and patients for prescription approval.
• Assist Medicaid patients in Alaska and Seattle, to have pharmaceutical claims successfully approved.
• Recognizes opportunities, obstacles and risks and take the reimbursement actions required to support existing and future business.
• Responsible for case on going case assignments, often life sustaining therapies.
• Managing individual cases and serve as a comprehensive resource to patients, physicians, manufacturer representatives, and other healthcare professionals in need of support services.
• Providing the highest level of reimbursement research/ verifications that must be met in order to insulate all parties from unforeseen financial obligations/ risks.
• Researching coverage for products by contacting insurers, maintain a database of patient data (insurance and physician information) to communicate with these groups on a daily basis via phone and fax, obtain prior authorizations, and work with the patient assistance program. Adhering to HIPAA rules and regulations.

Environment: TheraCall, PowerPoint, Excel, Medicaid, Medicare, Managed Care

Confidential, Beltsville, MD

Customer Service Specialist/QA Backup

Responsibilities:

• Demonstrates professional etiquette and courtesy when interfacing with customers.
• Resolves patient/customer complaints by identifying problems and coordinating appropriate corrective action.
• Ensures service intake procedures facilitate seamless operation between departments and/or other branch offices.
• Troubleshoots problems regarding orders; Schedules, coaches and organizes work assignments
• Review revenue management transactions (data or phone) to ensure that Apria's standard operating procedures have been followed
• Document outcomes of quality assurance review; Coordinate feedback on errors identified to the customer care center (CCC) or to outsource vendor management
• Propose updates to existing processes or documentation to the continuous quality improvement (CAI) or documentation teams.
• Performs follow-up on outstanding Certificates of Medical Necessity (CMNs), prescriptions and processes renewal CMNs/prescriptions through the use of suspended billing reports.
• Maintains and monitors follow up system to confirm that action takes place per Apria "best practices".
• Performs timely follow-up on renewal authorizations to maintain reimbursement activity.
• Contacts patient to gain involvement in problematic situations.
• Elevates aged prescriptions to manager for decision and resolution.
• Evaluates all completed CMNs/prescriptions/authorizations to ensure that the appropriate information has been obtained to allow for reimbursement as well as compliance with applicable standards and regulations.
• Enters CMNs/prescription information into computer once the prescriptions are completed and returned from the physicians.
• Documents all account activity on system. May perform internal quality audits to ensure that all necessary documentation is included in each patient file.
• Processes, reviews and mails prescription and/or CMNs to physicians for signature.
• Provides feedback on errors identified to the appropriate supervisor through the use of the ENF process or other accepted method.
• Researches diagnosis and insurance benefits to receive proper reimbursement.
• Assists in obtaining authorization for reimbursement for some accounts.
• Requests adjustments on accounts and recommends necessary changes to supervisor.
• Provide quality client service by managing and maintaining current relations with the VA and other healthcare customers on a day-to-day basis.

Environment: ACIS, Microsoft Word and Excel, Medicaid, Medicare, Tricare, Managed Care

Confidential, Columbia, SC

Veterans Claims Analyst/Examiner (Section Team Lead)

Responsibilities:

• Working within a team environment and serves as a counselor or advocate for VA claimants providing information about a broad range of benefits and assisting with applications for VA benefits and services.
• A legal technician conducting interviews and gathering requisite evidence from medical, military, community, and other sources to support benefit determinations.
• A decision maker weighing the evidence and applying the controlling laws and regulations.
• Responsible for making determinations pertaining to such matters as entitlement to medical or dental treatment, eligibility for vocational rehabilitation and education benefits, funeral expenses, civil service preference certificates, and entitlement to certificates for State and local bonuses, licenses, or privileges.
• A computer systems user who enters appropriate data to generate accurate benefits payments, controls pending issues or schedules future actions, and releases complete, correct notifications of benefits determinations
• Reviewing claims and creating a debt when an overpayment/incorrect payment has been processed/approved in error to recoup funds and redistribute correctly in accordance with federal rules and regulations and report the findings.
• Provide quality client service by managing and maintaining current relations with the VA and other healthcare customers on a day-to-day basis.

Environment: Vetsnet, VA Benefits, TRICARE

Confidential, Silver Spring, MD

Team Lead/New Applications Trainer (Supervisor Assistant)/Member & Provider Services Specialist

Responsibilities:

• Liaison between the business and the technical teams .
• Research and respond to all Member Services Department calls in accordance with compliance guidelines (handling heavy inbound calls), providing information and general assistance to existing and prospective members and those interested in a group and non-group enrollment.
• Working with the tester to ensure requirements are met for any system development, and modifications or data extracts .
• Assisting providers with eligibility and claims questions/concerns.
• Assist the Health Plan by responding to general and complex inquiries from existing members, prospective members and groups (typing, filing and emailing; data entry). Independently analyze, resolve and respond to various inquiries providing definitive answers.
• Quality Assurance auditing of cases, documentation, phone monitoring
• Trainer of new staff/team members on health plan policies, procedures and product offerings; Develop and administer training courses and materials
• Conducting claim audits and customer service phone audits (keeping record of results and statistics)
• Assisting claims and IT departments with benefit/enrollment uploads (ensuring the correct benefit plan was loaded to prevent incorrect claim processing errors); assisting on process flow issues between the enrollment/benefit system & claim processing
• Worked with marketing department and IT department on requirements flow between benefits system and the claims processing system (ensuring the correct benefits and claims coding were accurate); configuration of claims system for specified employer group contracts
• Assisted with loading employer group and physician contracts into benefits system, ensuring information was entered correctly by running “test” claims to confirm plan was loaded accurately
• Assist in providing back up in claims/appeal processes
• Reviewing referrals for accuracy & completeness
• Develop and implement a company-wide Quality Management Plan
• Documented and maintained comprehensive case investigative files to preserve as potentially discoverable material
• Legally documents and maintains comprehensive case investigative files to preserve as potentially discoverable material. Includes composing formal correspondence and detailed technical writing of reports and synopses .
• Supported management and directors by providing input into the coordination, planning, organizing and direction of the case workload and assisted less experienced staff
• Develops and conducts investigations by performing complex fraud and/or abuse theory-approach analyses and audits of financial business records, provider and subscriber medical data, claims, systems’ reports, and internal investigations as required.
• Develops documentation to substantiate findings using PC based spreadsheets
• Collaborate with Directors and Managers to identify key Quality Management metrics and monitor performance
• Review departmental SOPs and desk procedures for accuracy, completeness and consistency

Environment: Macess EXP, Kmate, Diamond, HealthConnect, Lotus Notes, Epic, Medicare & Managed Care Claims