Qualifications Summary

Highly trained and experience System Tester and Patient Analyst with over 10 years' experience in Medical Claims and Processing. Knowledge of HCPCS and CPT and ICD-10 coding as well as medical terminology healthcare payers Medicare, Medicaid, Proficient use of Medical Software file maintenance downloading data, and testing of Software and trained in medical software applications: Talent for identifying customer/client needs. Experience with the following software MCS for Medicare, NextGen, Medical Manager, CUBS, HBOC, Star Patient Accounting, Healthport, Chartmax, Centrix, HP Quality Center, MITS, Sharepoint, CGX, SQL, Quick Test Pro. All Microsoft Office and other Healthcare applications.

Professional Experience

Confidential

System Analyst/ Auditor

• Verifying correct icd-9 and hcpcs codes were used for claims submission.
• Updating provider information for pricing guidelines and contract purposes.
• Requesting medical records for verification of insurance and coding.
• QA on test cases that were executed to ensure accuracy.
• Analyze requirements, create test scenarios and scripts, and execute scripts.
• Core Business Support for system maintenance and break/fix testing.
• Responsible for planning and conducting a wide range of quality control tests.
• Implement different ways to improve quality claims submission for accurate and timely payment to providers and beneficiaries.

Confidential

System Tester/ BA

• Executing tests for MCS system for CMS/ Centers for Medicare and Medicaid to ensure correct electronic claim payments and denials.
• Writing test cases as assigned by CMS for System Changes.
• Updating System codes for ICD-10 and HCPT codes per request from CMS.
• Ensure all system testing was completed by required deadline by CMS.
• Perform test planning, test design and test execution..
• Implement different ways to improve quality claims submission for accurate and timely payment to providers and beneficiaries.
• Test case mapping with Quality Center
• QA on test cases that were executed to ensure accuracy.
• Analyze requirements, create test scenarios and scripts, and execute scripts.
• Core Business Support for system maintenance and break/fix testing
• Responsible for planning and conducting a wide range of quality control tests.

Confidential

Medicare Biller/ A/R Specialist

• Submitting electronic and paper claims to the correct Medicare payer for Medical and DME claims.
• Follow- up on submitted, pending or denied claims.
• Filing proper paper work on denied claims for appeals and grievance for Medicare and Medicare MA plans.
• Follow up on all Medicare and commercial payers 120 days for payment with a 90 percent turnover.
• Correcting Coding errors for proper claim submission.
• Obtaining insurance info for authorizations and submitting them for any medically necessary services including therapy, surgery and DME.

Confidential

Provider/ Member Services

• Taking incoming calls from Providers to help them administer correct claims submission for payment. .
• Troubleshooting and responding to customer concerns or question regarding their specific policy or coverage file
• Checking claims in system for payments and processing.
• Working different projects regarding correspondence and customer satisfaction.
• Assisting the member with coverage, authorizations and grievance policies.

Confidential

Customer Service/System Analyst

• Taking incoming calls from beneficiaries to help explain there Medicare coverage.
• Assisting beneficiaries with navigating thru Medicare website to find Doctors or understand their policy and coverage.
• Checking claims in system for payments and processing.
• Working different projects regarding correspondence and correct claims processing.
• Updated the system with current ICD-9 CPT codes for electronic claims submission.
• Running test on system software for correct electronic processing and payments
• Correcting and updating audits per CMS requirements
• Test case mapping and writing business requirements
• Executing tests for MCS system for CMS/ Centers for Medicare and Medicaid to ensure correct electronic claim payments and denials.
• Writing test cases as assigned by CMS for System Changes.
• Updating System codes for ICD-9 and HCPT codes per request from CMS.
• Ensure all system testing was completed by required deadline by CMS.
• Updated provider and pricing files to ensure correct claim processing.
• Implement different ways to improve quality claims submission for accurate and timely payment to providers and beneficiaries.
• Test case mapping with Quality Center
• QA on test cases that were executed to ensure accuracy.

Confidential

Medicare Biller

• Processing claims electronically in Medipac and Cubs for payment from Medicare.
• Checking claims for error and status on FSS system for Medicare Part A and B thru UGS.
• Correcting any errors in FSS system and refilling claim with Medicare.
• Entering claims in FSS system to be processed for processing.
• Sending claims to Secondary payers to process claims for payments.
• Taking incoming calls from beneficiaries regarding their accounts and resolutions.

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Confidential

Account Resolutions Specialists

• Making outgoing calls to resolve patient balances, setting up the best possible arrangement for the patient and the client.
• Calling insurance companies for follow-up on receipt of claim and payment.
• Helping patients understand their insurance policies regarding deductible co-pays and coinsurance.
• Sending UB92 or HICFA forms for prompt payment of insurance claims.
• Sending claims to Secondary payers to process claims for payments

Confidential

Medical Receptionist

• Answering Multiline phone system directing them to the proper area.
• Taking Cardiac Consults and forwarding them to the correct On-call Cardiologist.
• Filing and Requesting medical records.
• Scheduling Family Consultations for patients undergoing surgery.
• Working various projects using Microsoft office regarding patient and storage files.

Confidential

Patient Analyst

• Taking 150-180 calls a day to assist patients with their billing statements and resolving patient accounts.
• Working reports using Microsoft office to reduce A/R, and collect on patient accounts.
• Calling insurance companies for follow-up on receipt of claim and payment.
• Helping patients understand their insurance policies regarding deductible co-pays and coinsurance.
• Sending UB92 or HICFA forms for prompt payment of insurance claims.
• Sending claims to Secondary payers to process claims for payments.