Sharlita Giles, Mpa Email & Phone Number

Atlanta, Georgia, United States

Responsible for assisting with the oversight of the day-to-day activities of the Revenue Cycle Management departments day to day operations and processes.

*Research payer denials related to referrals, pre-authorization, medical necessity, and non-covered services, resulting in denials and delays in payment.*Initiate appeals and Letters of Medical Necessity in partnership with the ordering MDs.*Submits detailed, customized appeals to payers based on review of medical records and in accordance with third-party guidelines.*Verifies medication charges are documented appropriately in financial, clinical, and operational areas (i.e., medical records, claims, itemized bills)*Utilizes knowledge from appeals to initiate prevention of claim denials in advance of infusion services.*Monitors and reports outcomes of denials and provides recommendations for improvement across and within processes*Communicates denial and billing issues to the RCM leaders in coding and billing*Formulates recommendations and assists with implementation of changes*Disseminates medication-related regulatory/coding/billing information to internal customers*Responds to ad hoc Infusion medication billing or reimbursement questions*Assures appropriate reimbursement by payors by comparing actual versus expected medication reimbursement rates*Follows-up with Revenue Cycle team on resubmitted Infusion claims until the accounts are at a zero balance or expected payment is received by payor*Providers support to MDs for Peer-to-Peer reviews as appropriate to resolve denials*Identifies denial patterns and escalates to RCM leadership as appropriate with sufficient information for additional follow-up, and/or root cause resolution*Completes recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials*Reviews payor communications, identifying risk for reduction in reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting and Revenue Cycle leadership as appropriate.

Duluth, Georgia, United States

➢ Responsible for taking data provided and submitting claims to various private and government-sponsored insurance companies. File both 1500 and UB claims; including paper and electronic means.➢ Follow up with pending claims and work denials for all payers.➢ Query information on remote Medicare software.➢ Learned new systems and process solutions as they presented themselves to ensure proper assignment and workflow.➢ Contact insurance companies/payers or patients to gather information necessary to complete appeal processing.➢ Remain compliant with our policies, process, and legal guidelines.➢ Received ongoing feedback and coaching aimed at improving performance.➢ Compliant with HIPPA and other State and Federal regulations.

Greater Atlanta Area

Verify applicable eligibility for sharing requests for procedures to include surgical intervention, diagnostic testing and both inpatient/outpatient operations• Notify the provider/member in writing of the determination, whether the procedure is approved or denied• Review medical narratives to identify the nature of a condition and whether it is pre-existing, chronic or acute• Collaborate with others on conditions in question and identify cases that require the intervention of a Medical Review Officer• Member/Provider requests are reviewed in a timely manner while demonstrating excellent customer service to patients and healthcare professionals

Atlanta Georgia

➢ Responsible for reviewing electronic and paper EOBs for denial and underpayments, analyze denial data, generate management reporting of activity and assist in resolution of identified issues. Analysis of electronic and paper EOB’s denial and payments posted. ➢ Conduct claims analysis and review to address patterns of denials and/or underpayments. ➢ Identifying trends or problem carriers, communicate areas of concern and present ideas to correct or prevent future issues. ➢ Interact with other departments in the resolution of identified issues preventing clean claims. ➢ Track resolution of identified issues. ➢ Complete special projects as assigned by supervisor/manager. ➢ Successfully manage over 700 accounts with over two million dollars monthly revenue.

➢ Responsible for the adjudication, resolution, and payment of Medicare Part A claims and Medicare Part B claims.➢ Responsible for a variety of support functions in order to ensure proper claims processing and payment. ➢ Responsible for handling all stakeholder inquiries and education regarding the proper submission of those claims.➢ Responsible for the analysis of appeal requests in order to reduce billing and pre-payment errors by providing feedback to the claims processing areas and to the physicians and suppliers.➢ Responsible for auditing the quality of appeals letters and tasks related to the appeal process and preparing reports to the Unit Manager reflecting the audit results; monitoring the workload and age lists to ensure that all cases are being completed timely according to CMS guidelines; and conducting training of both new and existing unit members on subjects identified as weak areas as a result of audit results or feedback from other operational areas. ➢ Responsible for completing the monthly CMS reports.➢ Served as Subject Matter Expert at annual conference and regional shows.

➢ Handles incoming telephone reopening, while documenting all additional information supplied by providers and initiating additional contacts for more information if needed to correct processing of any claim identified as processed incorrectly.➢ Compares the original claim filed with the payment or denial issued to identify if any contractor and/or provider errors have occurred.➢ Responsible for taking any necessary corrective action via the adjustment processes. ➢ Has a working knowledge of the system edits and audits for resolution of claim adjustment suspensions along with a thorough knowledge of Medicare coverage rules and guidelines ➢ Identifies valid and timely requests, researches patient claim history, develops for additional documentation when necessary, refers any cases requiring medical decision to the Medical Staff, refers any cases that are complex in nature to the Redetermination staff, effectuates claim decisions using the Multi-Carrier System (MCS), and tracking initiated work through completion.➢ Process claims that have been reviewed by Medical Review.➢ Research inquires sent via the customer service department regarding claims that have been possibly denied in error..

➢ Applies a comprehensive knowledge of claims processing, provider contracts and contract configuration to escalated provider inquiries.➢ Thoroughly researches escalated provider issues and takes appropriate action to resolve them within established service level agreements and quality standards.➢ Complies with all corporate and Provider Solutions Unit policies, procedures and workflows.➢ Serves as primary contact for Provider Relations for escalated provider issues.

➢ Answered clients’ questions about usage, benefits, claims, and billing ➢ Compiled, recorded, and evaluated personal and financial data in order to verify completeness and accuracy, and to determine eligibility status for any promotional deals. ➢ Extensive customer contact for resolution of billing problems, account activation, account changes and technical ➢ Interpreted and explained information such as eligibility requirements, application details, & payment methods➢ Handled re-routed inbound calls from consumers, and used influential skill to overcome objections and promote alternative products or service ➢ Proactively conducted strategic account reviews with all assigned customers on a regular basis to review service needs and usage trends➢ Identified products and pricing that meet customer needs and business objectives➢ Conducted Rate Reviews, Billing Disputes and Credits with strategic customers upon request➢ Ensured customers are proficient in using services by identifying user needs and providing training and consultative services➢ Managed, Supported, and Serviced the account related needs of an assigned set of strategic customers

➢ Monitored and responded to signals from alarm systems in accordance with policies and code regulations ➢ Provided timely, exemplary service to all associates and vendors while maintaining a calm, professional composure at all times ➢ Answered phone calls and assisted callers in a variety of situations, including calls regarding emergency situations➢ Dispatched both internal and third party alarm repair service providers to company facilities as needed➢ Demonstrated strong character; Built partnerships; Modeled a conscious balance between work and personal life and took personal responsibility for Personal and Professional Development➢ Monitored signals from alarm panels and react appropriately by following action plans and Accurately and completely documented all actions➢ Displayed Role model characteristics and demonstrated the company’s core values of respect, honesty, integrity, diversity, inclusion and safety of others

Master Of Business Administration (Mba), Public Administration

Bachelor Of Technical Management, Small Business And Entrepreneurship