Clinical Appeals Specialist Resume Profile

Objective

Obtain a position within a company, that will allow me the opportunity for professional growth based upon my performance and that will utilize my abilities developed through my education and experience.

Profile

Motivated, healthcare professional with 19 years experience in various healthcare related fields including Clinical Nursing, Utilization Management, Billing Collections, and Quality. Talent for quickly mastering health care system technology and proficient in Mircosoft Office software applications. Extremely analytical thinker with an aptitude for being a team leader and educator. Experience with training and education in a peer to peer or group setting. Accustomed to handling sensitive and confidential records while ensuring HIPAA guidelines are followed. Demonstrated history of producing accurate, timely reports, and meeting stringent deadlines.

Skills Summary

Management
Data Analysis Reporting
Coding
Microsoft Office Proficient
Appeals Denials

Training Education
Customer Service
Utilization Management
Marketing Sales
Contract Reimbursement

Billing Collections
Quality Improvement
Community Outreach
Professional Presentations
Compliance Audit

Professional Experience

Confidential

AR Operations Supervisor/Certified Coder

Management of the day to day workflow of the Customer Service, Insurance Review, and Billing Collections departments.
Monitoring of daily claim production and timely submission of electronic/paper claims
Identification and resolution of systemic issues related to accounts receivable billing issues
Tracking, trending, and resolution of denied claims or unresolved accounts
Monitoring and reporting of outstanding AR based on departmental benchmarks
Development of educational materials and ongoing training of Providers and Departmental Staff regarding documentation and coding guidelines
Audit and review of clinical information from medical records, charts and documents to ensure appropriate ICD-9 and/or CPT-4 and HCPS coding
Manage the CPT-4 and ICD-9 database within ECW to ensure coding information is updated and accurate
Monitor the review of patient accounts for accuracy prior to submission to the Collection Agency
Evaluate processes within area of responsibility in order to recommend and participate in process improvement initiatives.

Confidential

Auditor/Fraud Field Investigator

Analyze, audit, and investigate TennCare/Medicaid claims data to identify trends or anomalies to determine if Fraud, Waste, or Abuse has occurred
Review of Medical records and payment data to ensure coding and clinical guidelines are being followed
Creation and presentation of detailed reports regarding fraudulent activities identified
Work closely with TennCare MCOs, TBI, and OIG on all open cases

Confidential

Clinical Appeals Specialist

Development and maintainence of clinical appeals process for 30 facilities in various regions
Review of medical records for determination of severity of illness and intensity of service of charges denied by payors for medical necessity and submission of formal appeal for payment
Review of medical records and claims for verification for correcting billing and coding for services and procedures provided
Instrumental in setting companies highest overturn rate for clinical denials

Confidential

Community Outreach Manager

Community Outreach Team Lead

Community and Outreach Education Coordinator

Management of the Community Outreach Department for a Medicare Advantage Insurance Plan.
Partner with Sales, Member Services, and Network Operations Departments to assist with company growth by the development and implementation of strategic outreach plans in current markets and expansion areas.
Development and maintenance of tracking system for reporting and monitoring of community outreach programs and events to ensure budget and CMS guidelines restraints are met.
Research and Development of Health Education programs and materials geared toward the senior community.
Maintain and nurture contacts within the senior community while promoting a positive company image.
Conduct educational seminars and health screenings for the senior community in Davidson County and surrounding counties.

Confidential

Resident Care Director

Management of Resident care staff of 40for an Assisted Living Facility.
Monitoring and Implementation of state guidelines and regulations to insure facility compliance.
Education and training of Resident care staff in regards to proper medication supervision and resident care.
Assessment of Residents to insure appropriateness for facility placement and level of care required.

Confidential

Reimbursement/Collections Manager

Management of the Reimbursement, Collections, and File Maintenance Departments with at total staff of 23 for a Physical Therapy Central Billing Office.
Training and education of staff on new Claims and Billing system.
Set up and maintenance of all Payor contracts, claims billing information, and formats in Patient Accounting system.
Analysis and review of current contracts for payment consistency and profitability.
Development and implementation of workplan for resolution of outstanding AR over 60 days old.

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