Crystal Dailey Email & Phone Number

Hamden, Ct, Us

Remote

Develops and maintains positive provider relationships with provider community by regular and/or virtual/digital visits, communicating administrative and programmatic changes, and facilitating education and the resolution of provider issues.Periodic on-site visits as needed.Serves as a knowledge and resource expert regarding the most complex provider issues impacting provider satisfaction; researches and resolves the most complex provider issues and appeals for prompt resolution.Works with internal matrix partners to triage issues and submit work requests.Is assigned all Tiers of Hospitals/Facilities and/or National Ancillary provider groups.Functions as a high level technical resource to resolve or facilitate complex provider issues.In collaboration with Provider Experience, coordinates Joint Operation Committees (JOC) of hospital/facility and/or National Ancillary provider groups, driving the meetings in the discussion of issues and changes.Provides assistance regarding Annual Provider Satisfaction Surveys and required corrective action plan implementation and monitoring education, contract questions and non-routine claim issues.Coordinates communications process on such issues as administrative and medical policy, reimbursement and provider utilization patterns. Manages inventory impacting up to $500M A/R.Conducts claim and trend analysis.Coordinates prompt claims resolution through direct contact with providers, claims, pricing and medical management department.Identifies and reports on provider utilization patterns which have a direct impact on the quality of service delivery.Researches issues that may impact future provider negotiations or jeopardize network retention.May be responsible for monitoring department metrics, provider assignments and oversight of daily activities.

Remote

Work At Home

Ensures accurate adjudication of Behavioral Health claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. Primary duties may include, but are not limited to: •Reviews company specific, state contract specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducts clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy. •Translates Behavioral Health medical policies into reimbursement rules. •Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits. •Coordinates research and responds to system inquiries and appeals.•Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.•Performs pre-adjudication claims reviews to ensure proper coding was used.•May assist with the preparation of correspondence to providers regarding coding and fee schedule updates.•Trains Behavioral Health staff on system issues.•Works with provider contracting staff when new/modified reimbursement contracts are needed.

Wallingford, Ct

Provides accurate, timely maintenance of complex provider and reimbursement information. Primary duties include, but are not limited to: Synchronizes data on claims and provider databases and provides expertise on business requirements for multiple business regions. Identifies, analyzes, and resolves issues for multiple system provider databases. Participates in system testing and analysis in support of new functionality, new system processes, and business rules changes. Validates the data to be housed on provider databases and ensures adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Researches and resolves complex exceptions and error reports. Determines regional/cap/business indicators for multiple business areas to assure accurate reimbursement based on provider contract and area fee schedules. Determines training needs and provides training to less experienced associates and outside customers on multiple provider data base systems and with multiple business requirements.

Bronx, N.Y.

Collected and confirmed data for Medicare A Billing. Confirmed Medicare SNF days available. Implemented and maintained financial changes to resident charges and rosters. Inputted correct diagnosis, qualifying hospital stays and prior SNF stays for education of claims. Issued Medicare related letters to resident, and their families. Communicated with various vendors, suppliers, and ancillary service personnel. Maintained compliance with federal, state, and local regulations for the resident and facility. Responded to Medicare A appeals, follow up, resubmit claims and appeal denied claims.

White Plains, N.Y.

Responsible for billing, payment posting, A/R follow-up, collections, charge entry, and coding. Audited accounts to ensure appropriate reimbursements based upon contracts with various payors. Obtained authorizations from insurance companies, insurance verifications, and banking. Performed high level appeals that required contacting insurance companies for second level appeals and writing correspondence to local and state offices to dispute denials of claims from insurance companies.

New York, N.Y.

Oversee daily operations in the office, and office staff. Responsible for physician credentialing, and maintain personal schedule, banking, and bookkeeping. Responsible for billing, payment posting, A/R follow-up, collections, coding. Responsible for booking and coordinating surgical procedures, scheduling appointments and medical tests. Responsible for obtaining authorizations from insurance companies. Duties included supervision of staff, hiring and training of Medical Secretaries, Medical Assistants, and File Clerk’s.

Yonkers, N.Y

Trained and supervised a staff of 6-8 Medical Assistants. Responsibilities included patient care and education, Vital Signs, EKG’s, Phlebotomy, Pulmonary Function testing, holter monitoring, giving injections and Immunizations. Performed wound care, dispensed medication, HIV testing and counseling. Phoned in prescriptions, screened laboratory work for abnormal results and followed up with patient care. Other duties include: ordering supplies, stocking exam rooms, and assisting physicians in multi-specialties’ with patient care. Responsible for scheduling appointments, handling phone calls, referrals, verifying insurance, and obtaining authorizations.

Bachelor Of Science - Bs, Health/Health Care Administration/Management

Education record

Health/Health Care Administration/Management

College For America at Southern New Hampshire University 1230 Elm Street Manchester, New Hampshire 03101