Monique Johns Email & Phone Number

• Follow up on outstanding Facility claims in Epic• Compare payments received to current provider/payor contracts to ensure accuracy of payments. Complete write-offs and contractual adjustments as necessary. • Identify and research claim denials.• Initiate Clinical Appeals and Underpayment Appeals as necessary. • Correct patient Eligibility/Enrollment issues to ensure claims are billed accurately and correctly. • Bill balances to patients as necessary. • Track and Trend recurring issues to stay ahead of system and process issues.• Collect and analyze data to provide feedback and suggestions on implementing new processes and procedures to streamline current processes and increase productivity.• Complete special projects and assignments outside of normal job description as needed.

Monroeville, Pennsylvania, United States

• Followed up on Home Infusion invoices submitted to Insurance companies to ensure prompt and timely payment and escalate issues as necessary. • Evaluated payments/denials received for correctness and ensure that they are applied appropriately. • Drafted written Appeals and Grievances when applicable for denied claims. • Identified bad debt write-offs and A/R adjustments. Initiate write-off and adjustments in accordance with policies and procedures. • Ensured that secondary bills and patient invoices are accurately generated and submitted on a timely basis. • Identified any overpayments and/or duplicate payments, investigate and resolve balances. Process refund requests, in accordance with policies and procedures. • Responsible for clean-up of over $6,000,000 in AR in a 3 month period – goal exceeded with minimum loss

Pittsburgh, Pennsylvania, United States

• Reviewed charts and applied the proper HCPCS and ICD-10 codes • Verified patient's insurance via phone or online payer portals • Initiated prior authorization requests when applicable • Billed Ambulance claims according to payer guidelines via HCFA 1500, electronic, etc. • Handled AR Review/Collections • Reviewed electronic and paper rejections/denials • Followed up with patients, payers and medical providers as necessary to obtain resolution • Reviewed EOBs to verify payments are accurate according to payer contracts • Applied the proper contractual adjustments • Billed secondary insurance or billed patient for applicable deductibles, coinsurances and copays • Followed and documented payer trends • Handled appeals/reconsiderations • Composed written Appeals, Grievances and Reconsiderations in order to resolve medical necessity denials, underpayments, etc. • Required to meet or exceed monthly productivity and quality goals

Pittsburgh, Pennsylvania, United States

• Utilized Accounts Receivable reports and identified accounts that are past timely payment • Made contact with insurance companies, vendors and patients to learn the status of payments • Drafted appeals, grievances and reconsideration requests to insurance companies to overturn denied or short paid DME claims • Re-billed claims that have not been received by insurance company/vendor and provide substantiating documentation if necessary • Obtained necessary documentation (updated medical orders/prescriptions, clinical notes, etc.) and submitted to insurance carrier for reconsideration of claims • Contacted patient, physician offices, and territory managers to relay and/or obtain pertinent information and/or documents necessary to aide in the collection of claims • Assisted in maintenance of spreadsheets for hearings and ALJ requests as needed • Submitted requests along with supporting documentation to CMS; tracked requests and followed up with CMS on requests that have not been scheduled • Prepared files for hearings and ALJ meetings and participate in those meetings • Required to meet or exceed set monthly productivity and cash collection goals

Monroeville, Pennsylvania, United States

• Analyzed insurance payments based on current U&C and contract pricing to ensure services have been reimbursed properly and accurately • Systematically initiate collection calls to insurance companies and prepare collection letters in accordance with targeted goals and department policies • Maintained bad debt at a percentage level of sales as outlined by department management • Assured timely submission and resolution of reimbursement appeals/grievances • Resolved internal and external customer questions including support to other departments with accounts receivable related inquiries • Resolved reimbursement discrepancies and maintain customer assistance programs • Prepared accounts receivable summaries and reviews • Assisted in Training and Developing of new Hires

Pittsburgh, Pennsylvania, United States

• Handled the daily operations of the drug utilization review (DUR) initiatives within the Medical and Pharmacy Affairs Department • Closed and Incentive Formulary exception requests • Handled Prior Authorizations • Managed Rx Coverage edits • The DUR programs are applicable across all lines of business (HMO, POS, PPO, Indemnity, Medicare Part D, etc.); I served as a front--line DUR representative by taking incoming phone calls and answering questions about DUR initiatives from providers (physicians and pharmacists) • Answered cases generated and forwarded by external providers and other departments as well as questions from internal sources including, Member Services, HMS, and Sales. • Prepared, documented and communicated decisions for initial coverage determinations and appeal cases. • Maintained a database and filing system for initial coverage determinations and appeal cases as well as being responsible for tabulating DUR program statistics • Made outbound phone calls to members to notify them of coverage determinations • Provided assistance to the clinical staff with the implementation of new DUR initiatives and provided support with other special department projects • Met all compliance requirements regarding documentation, timeliness standards and identifying changes in workflow that would result in operational efficiencies

Pittsburgh, Pennsylvania, United States

• Provided prompt, accurate and courteous replies to written and telephonic inquiries involving a variety of issues including benefits, pricing, premiums, claim rejects and claim status • Responsible for handling a large volume of incoming calls from subscribers, providers, groups, agent plans and the general public • Required to meet daily evaluated quality and productivity standards • Provided services as a dedicated customer service rep for numerous clients • Served as the primary contact person for HR representatives at employer groups whom had their health insurance benefits with Highmark. • Responsible for handling inquires received via incoming calls, fax and e-mail as well as written correspondence • Assisted with training and mentoring of new employees in the department