Investigates, negotiates, bills and follows-up for payment regarding first and third-party claims involving any and all coverages, liability, and legal issues.Identifies viable payers, obtains IBs, UBs, HCFAs, correspondence, and medical records when necessary.Maintains the highest level of privacy in accordance with HIPAA requirements and laws.Works their inventory by route while maintaining an acceptable level of aged accounts receivable.Contacts patients, payers, hospitals, attorneys, employers, and any other parties involved to collect the necessary information and ensure reimbursement for our client.Recovers maximum dollars for the hospital through coordination of benefits in a timely manner.Appeals claims when applicable.Meets monthly company, team, and individual goals, and all deadlines set by the Team Lead and Manager, Operations.Completes special projects, as requested.

Under general supervision of the Patient Billing Supervisor, is responsible for the business and billing functions associated with worker’s compensation and motor vehicle accident medical claims. Interacts with patients, attorneys, adjusters, employers and insurance carrier staff to create billing accounts, obtain authorizations, fee negotiations, claims follow-up and resolution of all outstanding unpaid balances. Acts a resource to billing, patient financial services and all staff and patients for worker’s compensation and motor vehicle claim and billing processes.

*Responsible for research and resolution of all credit balances in software systems• Research and submit appeals & audits in a timely manner• Responsible for collection and resolution on accounts received in software systems• Research, prepare and complete any Write Offs• Follow up on collections and appeals in an efficient and timely manner• Demonstrate an ability to prioritize, multitask and utilize time efficiently• Demonstrate proficiency with software applications used by the company• Demonstrates the ability to clearly, accurately and concisely document notes in system per company guidelines• Other duties as assigned

• Worked for a Primary Care and Rheumatologist practice which included 3 doctors, 3 nurse practitioners, 3 nurses, several medical assistants and office staff. I was laid off from this position due to Covid-19.• Used Athena Health's A/R aging wizard to review the 30 day- over 120 days due reports• Noted patients accounts with balances, the name of Health Insurance last billed, date of service, deductible, co-insurance, copay or denial, the amount due and date of the note's creation• Made note of any contact such as, phone call or email.• Looked for cancelled insurance, incorrect insurance, or outdated copay amounts by checking details in quick view screen• Noted large balances and offered payment plans to patients• Followed up with patients regarding payment plans• Watched for claims that became stuck in the system with a payer or Athena• Used the Pay Span website to review BCBS, Harvard Pilgrim, Tufts and Fallon remits or explanations of payments• Used the Optum website to review remits or explanations of payments for all United Healthcarecorporate family of insurances including UMR, AARP, Medicare Replacement Plans and MedicareSupplement plans• Used Cigna website to review remits or explanations of payments• Resolved claims issues in a time sensitive manner• Used Athena Health as a resource to research claims• Corresponded with Health insurance companies, Worker's Compensation or Motor Vehicle Insurances to resolve claim issues• Appealed denials to Insurance companies• Requested Insurance recoupment or refund insurance regarding over-payments• Monitored infusion claims status• Faxed explanations of benefits to Medication Copay Assistance programs• Followed Athena Health Weekly Best Practices Related to Refunds & Claim Management• Used Athena Health Billing Admin Function to review Enrollment Worklist• Reconciled the previous workday's electronic deposits using Athena and Clover• Corresponded with our providers through Centricity

*Processed all denied and unpaid claims submitted to insurance carriers to ensure payment is received• Reviewed denials on an explanation of benefits (EOB) statement and work on issues until resolved• Analyzed A/R (Accounts Receivable) reports to follow up on unpaid claims• Sent out appeals on claims as required• Submitted any required documentation to insurance companies as requested• Researched the claims for information in order to process bills in a timely manner• Communicated with insurance companies, adjustors and patients on a regular basis• Corrected any errors and resubmit all unprocessed or returned claims to insurance companies• Created UB92 and HCFA bills by performing data entry into the billing software

•Researched and obtained health, worker’s compensation and automobile insuranceinformation from doctor’s offices, hospitals, employers and patients.•Obtained authorization from commercial health insurance companies as well as worker’s compensation and automobile insurance carriers for Surgi-Care bracing and dme products. This involves working with case managers from health insurance companies as well as utilization review departments and adjusters for worker’s compensation carriers and automobile insurance companies.•Entered orders and bill insurance companies.•Answered incoming calls to Surgi-Care.•Maintained and organized all relevant paperwork.•Worked together with sales and brace fitters in the field as well as patientsregarding bracing orders.•Achieved team goals and standards such as working with fellow team members on tasksand keeping orders under 30 days.•Assist with the implementation of quality improvement program to meet Company,•State Federal and CHAP standards.

•Answered department telephone queue by responding to and servicing internal and external customer issues.•Initiated required investigation calls as well as correspondence to answer and resolve customer questions for all Tufts Health Plan products.•Initiated and document customer calls for COB and worker’ s compensation cases inthe appropriate computer systems.•Adjusted claims on a daily basis and determine if claims adjustments may be made byanalyzing fund availability and generating refund request letters if applicable.•Complied with all department and company guidelines and policies, as well as all applicable laws and regulations.•Understood & applied OBD Guidelines and the ability to read and comprehend legaldocuments.•Maintained ownership of unresolved issues until completely resolved.•Reviewed and analyzed member’ s claims history by accessing applicable computersystems.•Reviewed and analyzed applicable documentation to calculate Tufts Health Plan liability by determining either the appropriate claim period for post payment recovery or the appropriate claim for current recovery processing.•Completed special claims, customer service or investigative projects, which mayinclude review and analysis of several different product types as assigned bysupervisor. •Participated in initiatives or responds to requests for help tocontribute to team and department success.