Lori Mccarrell,Bs,Ssbb Email & Phone Number

Remote

• Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing proper sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete the request. Analyze errors and determine root causes for proper classification, trending, and remediation.• Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to… Show more • Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing proper sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete the request. Analyze errors and determine root causes for proper classification, trending, and remediation.• Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.• Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.• Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals by collecting data analysis.• Participate in regulatory and audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities. Show less

Greater Pittsburgh Area

Greater Pittsburgh Area

• Followed up and completed appeal process and outcome within 72-hour timeframe to meet company and Medicare regulatory requirements.• Obtained all pertinent documents needed to process appeal before sending to medical director for review such as medical records, CMS guidelines used, Appointment of Representative Form, POA, Medicare NOMNC • Sent Level Two appeals to the Medicare Independent External Review Unit (MAXIMUS) within 24 hours of denial.• Reviewed appeal cases for accuracy… Show more • Followed up and completed appeal process and outcome within 72-hour timeframe to meet company and Medicare regulatory requirements.• Obtained all pertinent documents needed to process appeal before sending to medical director for review such as medical records, CMS guidelines used, Appointment of Representative Form, POA, Medicare NOMNC • Sent Level Two appeals to the Medicare Independent External Review Unit (MAXIMUS) within 24 hours of denial.• Reviewed appeal cases for accuracy and quality assurance to maintain Aetna’s quality standards with Medicare and made updates as necessary.• Participated in Medicare department audits, ensuring compliance and quality assurance Show less

Greater Pittsburgh Area

• Aggressively pursued approvals, overturned denials, sought alternative methods of coverage, and established precedence with key payers by utilizing CMS guidelines.• Pursued legal action with payers, participating in hearings (ALJ, State Fair Hearings).• Tracked all cases in appeals for performance measurement and outcomes by collecting and analyzing data.• Maintained an overturn rate of 72%, meeting quality assurance standards of 94%-100%, Call Quality 100%, and no timely… Show more • Aggressively pursued approvals, overturned denials, sought alternative methods of coverage, and established precedence with key payers by utilizing CMS guidelines.• Pursued legal action with payers, participating in hearings (ALJ, State Fair Hearings).• Tracked all cases in appeals for performance measurement and outcomes by collecting and analyzing data.• Maintained an overturn rate of 72%, meeting quality assurance standards of 94%-100%, Call Quality 100%, and no timely filings.• Collected revenue of approximately $16 million per year as a department Show less

Upmc Corporate

Collections, denial trending, billing, commercial large balance, collecting $30 million per month with Children's Hospital of UPMC

Greater Pittsburgh Area

Collections for Children’s Hospital of Pittsburgh transplant accounts (organ transplant) • Overseen payer policies, contracts and single case agreements• Calculated expected payments based on payer and organ received and confirmed accuracy• Utilized A/R reports to follow up on timely payments from insurance companies • Collaborated with patient’s families to retrieve pertinent and necessary information needed to obtain payment from insurance company• Medical billing:… Show more Collections for Children’s Hospital of Pittsburgh transplant accounts (organ transplant) • Overseen payer policies, contracts and single case agreements• Calculated expected payments based on payer and organ received and confirmed accuracy• Utilized A/R reports to follow up on timely payments from insurance companies • Collaborated with patient’s families to retrieve pertinent and necessary information needed to obtain payment from insurance company• Medical billing: rebilling corrected claims to insurance company Show less

Greater Pittsburgh Area

Worked with Autistic children and their families in the homes,schools and community

San Antonio, Texas

Worked in Virology and Immunology at the Armstrong Epidemiology Research Laboratory in San Antonio, TX. Brooks AFB. Also, completed 13.5 months of medical lab training with 9 months at Wilford Hall Medical Center in San Antonio, TX. Lackland AFB.

Certification, Data Analytics And Artificial Intelligence, A

Excel Data Analytics skills, SQL, Python, Tableau, Pytab Artificial Intelligence-Create a Bot, Virtual Assistant, Chap GPT, DALL-E.

Bachelor Of Science (B.S.), Finance, General

Activities and Societies: participant and finalist in Private Business Valuation Challenge UMUC team in Seattle, WA. Participant.

Masters Certificate, Lean Six Sigma Bb Masters Certificate, A

Activities and Societies: completed a black belt project with emphasis in finance ,this project was graded by a certified LSSBB completed.

Bs, Health Administration

Healthcare Administration, accounting, business writing

Science

Clinical Laboratory Science/Medical Technology/Technologist

Completed MLT school 13.5 months then took general education courses to include English, Psychology, College Algebra, Spanish, Anatomy.