Sheila Johnson Email and Phone Number

Provide day to day direction to the Payment Compliance team which is responsible for the maximization and collection of reimbursement by identifying contractual variance between posted and expected contractual amounts for managed care, governmental payers, and other various payers. The Payment Compliance team identifies and collects underpayments, along with resolving contractual overpayments. In addition, the team uses payer escalations and litigation to maximize collections as part of the Patient Financial Services for Community Health Systems. • Supervise the training and development program of PCCM personnel to ensure successful performance and outcomes• Recommend and monitor key performance indicators to ensure corrective action is taken by leadership when benchmarks are not met by PCCM personnel• Maintains and creates best practice processes to ensure optimal revenue capture• Maximize functionality of available technologies to ensure efficiency, accuracy, and value• Organize workload and resources to accomplish required objectives and to meet assigned deadlines• Maintain consistent and stellar performance while ensuring beneficial relationships with internal business partners, vendors and other essential parties• Provide feedback to managed care leadership on recommended language and mechanisms to ensure that deficits are addressed and net revenue is maximized• Provide feedback to revenue cycle business partners when opportunities for improvement are identified• Provide meaningful performance and financial reporting to internal customers and executive leadership• Monitor changes in coding, charge capture, and billing practices to anticipate impact on net revenue• Monitor changes in payor policies and reimbursement strategies to anticipate impact on net revenue• Ensure that net revenue opportunities are addressed promptly and aggressively in collaboration with business process stakeholders

Manage directly or through subordinate staff all aspects of the daily activities of the insurance department (60 employees) performing medical claims billing and account follow-up ensuring timely and accurate payment resolution on commercial and government insurance payers.

Manage activities of client services and support personnel. Address escalated inquiries from clients. Assure staff is provided proper training, instructions, tools, and methods to perform their jobs. Assure customer service follow-up methods and procedures are complete and meet time standards. Handle workflow, staffing and employee issues, and confirm departmental policy and procedures are performed. Created client services performance rubric and implemented a quality assurance program.

Managed and executed daily activities of support personnel and processors. Monitored and improved the quality of support services in accordance with contractual requirements. Created various training curriculums including but not limited to Medicare/Medicaid Low Income Subsidy programs. Ensured staff was trained, coached and followed policies and procedures. Implemented and maintained performance metrics and reports. Develop quality standards and validity process. Assisted with processing system design, created testing material and performed regression testing.

Reviewed Medicare Advantage Organizations enrollment documentation making determinations based on Medicare guidance. Processed transactions in multiple Medicare systems. Worked on special contracts auditing medical records for correct coding.

Supervised seven reimbursement representatives and directed accounts receivable activities for nine service centers. Helped representatives solve complicated billing issues and work with center teams to resolve any documentation concerns regarding patient claims. Conducted quality assurance on reimbursement documentation and procedures. Guaranteed compliance of all government and state regulations.

Oversaw human resource activities of 18 auditors validating medical claims reimbursements in clients processing systems. Trained auditors on client’s medical claims processing systems, along with coding and reimbursement methodologies. Analyzed complex medical claim’s payment issues. Handled internal and external communications of assigned clients. Implemented new clients with ongoing project management. Managed committee looking for overpayment opportunities for business growth. Collaborate with business partners to find solutions to business needs.

Assured the effective operation of the clinic’s front office, including training and supervision of staff responsible for scheduling appointments, answering phones, and checking patients in and out of appointments. Directed and motivated staff to take action that consistently delivered high quality patient care and an exceptional patient experience.

Maintained current knowledge of assigned plans and effectively applied knowledge in the payment of claims, customer service, and all other job functions. Provided customer service by responding to and documenting telephone and/or written inquiries. Consistently met established performance standards, including quantity and quality claims processing standards. Provide back-up on other accounts as necessary.

Reviewed and adjudicated medical claims according to processing guidelines and contracts. Used industry coding standards and reimbursement methodology - CPT, ICD-9, DRGs, HCPCS, ASC Grouper listings. Read and assessed medical documents with knowledge of medical terminology. Trained new employees. Performed claims post-payment audits and adjustments.