Detailed knowledge of Medicare, Medicaid, BCBS and commercial payers billing, payment process, denials, and appeals protocol Assess accounts from claim inception to full payment resolution Providing management with payer trends resulting in a delay or partial payment of claim/s Escalate exhausted appeal efforts for resolution by leadership Working high dollar and/or aging projects as directed. Submitting adjustments to resolve aged accounts to zero balance Providing detailed denial information to other departments assisting in claim processing Providing payer requested documentation required to process claims Researching with payer or patient the coordination of benefits to confirm the accuracy of primary or secondary medical coverage Effectively documenting accounts via Epic Systems

Managed medical records by following up with insurance companies, doctors’ offices and pharmacy issues on plan benefits or outstanding balances Managed household expenses, doctor’s appointments and activities of daily living Coordinated with family members on sensitive and confidential decisions regarding medical care

Validate denial reasons by contacting payer for accuracy or via Centers for Medicare & Medicaid Services Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations. Follow specific payer guidelines for appeals submission. Escalate exhausted appeal efforts for resolution. Work payer projects as directed. Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments. Perform research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately. Escalate denial or payment variance trends to NIC leadership team for payor escalation.

Attend and observe trials, hearings or other judicial and administrative proceedingsEnter court dates into Trial CalendarProcesses forms: Request for Terminations and New ComplaintsResearch juvenile information using Juvenile Court Activity Tracking System (JCATS) Enter case dispositions into TrackerSend Victim Impact PacketsOpen new juvenile cases TrackerClose juvenile case files in TrackerPull case files, witness list and calendar for morning and afternoon courtsStamp all mail received from Clerk of the CourtsSpecial Projects as assigned

Verification of eligibility for services rendered Performed Revenue Cycle Management by tracking rejected or denied claims from patient treatment to processed and final payment of claim Resolved reconciliation issues with billing companies Created open line of communication between the company and the client Assisted in the development of complex spreadsheets Assisted team members/directors/Gateway Liaison with issues listed on the edit list, denial or rejections via task manager Confirmation of received files, and anesthesia claims adjudicated for processing in a timely manner Prepare and distribute correspondence, project updates, presentations and other documents Served as knowledge base for others working within the department Effective communication with staff/management to resolve any issues EOB payment and charge posting corrections when required to obtain clean claims processing to payment

Interpretation of medical reports and data to assign ICD-9 codes Ensure compliance with all policies, procedures and directives Reviewed and validated accuracy of charges, including dates of service, types of services provided, location and patient identification Researched all rejected claims and provided proper follow up Worked alongside Facility Managers to maximize productivity Corrected and resubmitted rejected claims/or entire claim file when needed Escalated calls when boundaries of authority were passed Enrolled providers and practices with insurance companies for electronic claims and remittals Developed and prepared EDI documentation Identified and recognized opportunities to resolve problems related to EDI transactions EOB payment and charge posting corrections when required to obtain clean claims processing to payment

Build relationships with internal/external customers, and facilitate support for supply chain trading partners Properly enroll providers into the MMNS database Perform troubleshooting and support to billing agents and medical providers via email or inbound phone calls regarding rejected claims, carrier databases, or other technical problems Manage HIPAA and ANSI standard formats and proprietary layouts such as UB92, and NSF clearinghouse formats Monitor document transaction activity and resolve problems Trained new clients on use of software Created demonstrated software to be used by sales department Ensure providers are properly setup and authorized to submit electronic claims to various payers Assisted providers on credentialing process

Prepared spreadsheets for 835P, 837I and UB04 payer specific claims edits Consulted with various payers on testing edits and requirements for NPI Accurately performed File Transfer Protocol (FTP) Verified claims including the correct versions and formats for NPI transmission Provided transaction support and research for providers submitting directly to the company

Maintained a complete central filing system for highly confidential client files Managed admission process, admitting 30-40 patients monthly Scheduled patients while verifying insurance and referrals Performed extensive IT maintenance of clinical and billing database Coordinated accounts payable, employee benefits, and other human resources responsibilities i.e., payroll Created and submitted electronic claims to various payers for processing Provided diversified secretarial and administrative support to Executive Director

Performed troubleshooting and support to billing agents and medical providers via email or inbound calls regarding rejected claims, carrier databases and other technical problems Identified claim file as well as interface issues with appropriate internal or external resources to ensure timely resolution Thoroughly documented all calls, emails and work efforts to resolve providers and billing agents claims or payment issues Utilized various system tools to conduct audits on claims transmissions which failed to reach their electronic payer destination Decreased call abandonment rates from 10.1% to 2.9% and Increased service level from 62.6% to 83.5% Prepared adjudication letters for clients disputing timely filing rejections to obtain payment

Served as a Team Lead to employees, providing job training and guidance on a regular basis Managed multi-tiered, escalated customer service calls for Medical Manager(PCN), Medisoft and Lytec clients Provided senior level technical administration and guidance by responding to provider requests regarding various products and accounting issues Advised medical providers, billing agents and vendors on the process of a successful transmittal of claims to insurance companies Created technical bulletins for company’s Knowledge Base System as well as manual template Trained new hires and existing staff on use of company’s software products and applications