Roberta Smith Email & Phone Number

• Review and implement efficient and effective processes with regards to claims processing, including increasing or maintaining auto adjudication rates, operational activities such as encounter data submission, check run.
• Ensure claims are processed within regulated timeframes and according to all Medicare regulations and HMO contracts / DOFR.
• Coordinate plan audits, DOFR.
• Produce and review examiner productivity reports.
• Create and conduct corrective actions as required.
• Maintain and oversee the claims system software and other related software to confirm proper functionality and ensuring it meets the needs of the department.

• Assist with migration and upgrade testing and validation of data.
• Maintain a variety of system setup functions in proprietary claims management software which includes payer, provider, claims and user security data.
• Process claims for new client and audit and prepare the weekly check run.
• Create and update Auto Adjudication Rules.
• ICD-10 testing with internal staff and external clients.
• Assist with streamlining processes for EDI errors and claims processing.

US

• Assist with the transmission and receipt of HIPAA standard EDI transactions (including 837, 835, and 999) and act as the primary production support role as well as new EDI process development.
• Maintain a variety of system setup functions in proprietary claims management software which includes payer and provider data.
• Troubleshoot problems in EDI transmissions due to setup/system/map errors and correct in real time or report to appropriate staff to correct.
• Apply appropriate maps for inbound and outbound transmissions.
• Assist business users with production EDI tasks and communicating with business units to resolve EDI issues.
• Work with software vendor(s) to improve efficiencies in EDI file transmissions and various follow-up tasks through system automation or new work flow processes.

US

• Generate and send monthly 837 encounter transmissions after correcting any non-compliant errors.
• Audit and transmit 835 files for 7 clients multiple times a week.
• Assist in implementing HIPAA 820 transactions through the Market Place.
• Perform Compliance and upgrade testing for HIPAA transactions 837,834,835 and 820.
• Set up Trading Partners for the 820 transactions.
• Research data requests for the Claims and Provider Maintenance departments and respond for accurate claims processing.

• Audit weekly check runs for 5 medical groups processing HMO claims.
• Provide expertise and/or general claims support to teams in reviewing, researching, processing and adjusting claims
• Authorize appropriate payment or refer claims to investigators for further review
• Analyze and identify trends and provides reports as necessary
• Consistently meet established productivity, schedule adherence, and quality standards
• Supervise, monitor, track and direct day to day operations to staff