James Hedges, Cpa, Chda Email & Phone Number

United States

Fenton, Mi

Use data mining and analysis to represent client positions with healthcare reimbursement third party payer appeals and suggest improved billing.. Support contract negations between clients and third party payers. Among first in reimbursement community to use data analysis on outpatient claims with Blue Cross to file appeals of annual Cash Reconciliation. Recovered over $ 50.0 million for the industry. Identified issues have resulted in system/ process changes by Blue Cross. Designed and built Blue Cross Payment Validation product that utilizes 835 voucher files to predict year-end Blue Cross settlement, test Blue Cross BIP adjustments, improve budgeting and support contract negotiations, as well as project year-end cash position. Recent updates allow clients to validate their contractual modes with their auditors, generates Blue Cross voucher logs and identifies low paid claims for review and re-billing on a more timely basis.

Responsibilities include reviewing project documentation and collaborating with project managers to identify requirements to ensure that corporate information technology projects will comply with applicable laws such as HIPAA Privacy and Security, Medicare e-Prescribing and Stark/Anti-kick rules. Projects included: e-Prescribing, e-Registration, e-Enrollment for Individual Members.Deploy the HIPAA Security Self Assessment process enterprise-wide to ensure controls designed during implementation of the HIPAA Security Rule are still effective. I customized RiskWatch, a database tool built for hospitals to work for Blue Cross Blue Shield of Michigan.Used data mining to analyze claims data for data integrity issues and work with Information Services to ensure correction, report the financial impact to the company and the industry, and develop processes to recover overpayments due to non-compliance with the Participating Hospital Agreement. Recognized as an expert in the Michigan hospital reimbursement community on the summarized paid claim reports known as "front sheets", the underlying claims data and how they are reimbursed through the cost report.  As the project business leader, worked with Information Services to develop the process to transfer claims data from Blue Care Network’s Facets claim processing system to the parent. The data needed to be translated into the parent’s business rules before being loaded into the existing front sheets. Led and performed audits of Medicare and Blue Cross cost reports for hospitals ranging in size from 60 bed facilities to multiple- hospital health systems grossing over $1 billion in revenue.  Maintained and helped develop the Provider Audit/ Facility Reimbursement departmental databases that support three departments in two offices.

Taught Visual Basic and SQL Server Database. Incorporated information security into the relevant parts of the curriculum.

Developed and taught undergraduate and graduate-level course on information security based on BS 7799 (ISO 27000)

Detroit

Mscis, Software Management

Among first 50 people in US to pass BS 7799 Information Security Lead Auditor exam.

Bba, Accounting

Activities and Societies: Founder and President of Society of Investors and Entrepreneurs

Education record