Business professional specializing in operations management in the healthcare administrative sector. Highly skilled in revenue cycle, creating, and implementing procedures in various areas that impact reimbursement. Result driven professional, visionary, and innovative leader with proven record in improving various operations. Vastly focused on maximizing production with given resources.
- Microsoft Excel (Pivot Tables, Graphs, formulas)
- Medi - Soft Billing Software
- Groupcast Imaging System
- QNXT manage care system
- Centricity (IDX) billing software
- IBM- Cognos Impromptu Analyzer
- Knowledge of Microsoft Access Database
- ICD-9/ 10 CPT knowledge
- Knowledge of medical terminology
- Bilingual: English/Spanish
- 60 wpm and 10 key by touch
- Knowledge of insurance payer regulations/compliance requirement including CMS/Medicaid/Medical
- Coordinating internal resources and third party vendor for execution of projects and ensure projects are delivered on time.
- Identify current system challenges, future needs, and recommend system changes.
- Test software, make coding or development recommendations for enhanced system capabilities, ensure delivery of Project Order (PO), review development expenses, and approve invoices from third party development team.
- Manage the migration of data along with developers; audit data, run SQL queries for data validation, test, and track.
- Lead development team for implementation of system changes, weekly calls, and development meetings with involved stakeholders.
- Analyze, create, and deliver Account (Client) reports to CEO of open and closed A/R, deliver client reporting of services and savings, as well as forecast client future usage.
- Recommend process changes, create company P&P’s, and Operational Manuals.
- Additional duties include: hiring new staff, new staff, and account management.
- Senior Account manager for clients in entertainment; lead team assigned to the client firm and directly provide healthcare management and advocacy services.
Patient Accounts Manager & Business Analyst
- Fully in charge of creating a call center initially outsourced; collection of 1.2M a month with less expenses, resources, and improved customer service/patient satisfaction.
- Drafted cycle flow, diagram, implemented agent software, system upgrade, created work queues, phases, agent standard operating procedures, trained, developed staff, and ensured compliance.
- Lead team involved in the development and launch of call center; lawyers, IT developers, security committee, compliance team.
- Managed a team of 30+ employees for the patient accounts call center and self - pay department; hiring, reviews, Displinary and plans, coaching, and management of improved operations.
Eligibility Supervisor & Analyst
- Reduced open claims A/R by 50% in one quarter; implemented a change with outside vendor that can provide eligibility results quicker and accurately; assigned results effectively in grouped projects.
- Run various reports using Cognos, eligibility denial trending by region, insurance payer, benefits denial trending, research payer policies such as CMS, Medical, or Commercial payers for updated rules that may expand on benefits payable for the purpose of reimbursement, ensure staff is meeting goals, analyze open A/R aging, implement action plan, initiate projects, educate staff, or implement a process improvement.
Medical Record/Compliance Claims Lead & Analyst
- Assist in supervision, development, and coaching of 25+ employees. Ensure quality standards are met, analyze volumes and trends of claims denied for records/audits, assign projects, and identify process improvements.
- Analyze down coded underpaid claims as a result of audits and MR review.
- Ensure compliance of overpayment requests and refunds. Implemented the use of several databases that eliminated manual work, conducted effective tracking, created record request automatically (1,000 requests per week), and freed up several FTE’s to sort records within 48 hours, initially behind by three months.
- Work closely with Compliance Officer and Vice President (VP) of Health Service.
Healthcare Claims Business Analyst
- Responsible for analyzing all denials received within the Confidential - Central Business Office ( Confidential ).
- Analyze top insurance plans and top claim denials impacting incoming revenue. Identify internal or external factors (root cause) causing an increase in claim denials in any area of the revenue cycle, follow-up with recommendation, and action plan.
- Work closely with managers, assist with corrective action plans, new policy or procedure, follow-up, and report results.
- Scheduled conference calls with stakeholders causing claim denials if issue was external, discuss trends identified, action plan proposed, and collaborate with stakeholders to achieve results.
- Report variance changes and results of process improvements to Vice President (VP) of the Confidential .
Compliance & Claims Analyst
- In charge of creating policies and procedures for the new audit department opened within the Confidential .
- Department was responsible for compliance of audit requests stopping claims revenue from coming in, potential claims recovery, or overpayments.
- Review CMS rules, forms, and process of complying with audits throughout different Medicare Administrative Contractors (MAC), commercial, or Medicaid conducting audits.
- Analyze open claims A/R, identify provider opportunities, and conduct quality audits.