• Receive and track/trend Hospital and Professional claim denials.• Review and evaluate denials and write formal appeals for claim denials or assures assigned staff completes appeals appropriately applying the rules of severity of Illness, intensity of service, discharge screens/ indicators, 2 midnight rule, and Medicare inpatient only procedure list consistently in a timely fashion throughout the organization.• Cooperates with external reviewing/paying agencies (including Medicare MAC, and other third party payers as designated by contractual agreement) regarding the review of special cases for medical necessity and quality of care.• Works in close collaboration with the all Revenue Cycle and other Departments to provide feedback on opportunities for process improvement.• Designs, implements, monitors and improves denial and appeal process in accordance with policy.• Manages the Business Office staff that handle denial cases and retro-active Medicaid clinical authorizations in their daily activities assuring timely and accurate completion of their tasks.• Routine interdepartmental communication to update relevant parties and information systems with appeals decisions and outcomes or other relevant information.• Keeps abreast of current rules, regulations, policies, and procedures related to managed care contracts, utilization review, and appeals submission within the healthcare industry as whole with a focus on denial trends and tactics.

• Oversight of Revenue Integrity personnel in evaluating, reviewing, planning, implementing, and reporting various revenue management strategies to ensure CDM integrity. Maintained subject-matter expertise and capability on all clinical and diagnostic service lines related to revenue cycle operations, claims generation, and compliance.• CDM and charge practice corrective measures and monitoring to safeguard revenue cycle operations. Provided oversight for Revenue Integrity personnel monitoring statistics/key performance indicators to achieve sustainability of changes and compliance with regulatory/non-regulatory directives.• Assumed lead role and/or provide direction/oversight for special projects and special studies as required for new system integrations, system conversions, new facilities/acquisitions, new departments, new service lines, changes in regulations, legal reviews, hospital mergers, etc.• Maintained a high level understanding of accounting and general ledger practices as it relates to Revenue Cycle metrics. Established charges in appropriate revenue centers to positively affect revenue reporting.• Managed government and commercial payer audits to also include outlier payment review.

- Responsible for oversight of patient collections and financial counseling, insurance authorization, cash applications and credit balance teams. Lead day-to-day operations and broad scoped work assignments focused on maximizing quality and production processes.- Streamline existing processes, reorganizes work, and improved resource utilization for cash applications, insurance verification and patient collections teams.- Reports to track key performance indicators and monitor and manage overall patient collection performance.- Monitored and identified processes to be implemented in order to achieve key revenue cycle metrics including but not limited to cash collections, unbilled A/R, aging over 90 days, and Days in AR. .- Trend analysis on patient payment levels and denial rates to ensure that reimbursement was in accordance with allowable amounts stated in agreements and contracts.- Closely monitors denial trends and research root cause issues while developing solutions to improve overall denial metrics.- Month end reports to identify opportunities for process improvements with respect to claims denials and outstanding patient A/R.- Ensured that all payment posting is accurately posted and that effective balancing processes were in place and consistently followed.- Responsible for ensuring credit balance thresholds are met and processes were followed according to internal policies.- Resolve complex payer or physician issues when necessary. Acted as a primary point of escalation contact for clinical operations for day to day operational issues relating to billing, collections, and denials, and coding.- Comprehensive knowledge of payer billing requirements and reimbursement policies.- Communicated performance data and action plans to leadership.- Monitored the financial impact on the organization of prospective regulatory changes to Federal and State reimbursements.

• Efficiently manage a staff of 17 employees with multiple roles throughout the Revenue Cycle• Effectively manage the Revenue Integrity Team, Billing Team, Denials Team, and Contract Variance Team for Governmental Payers.• Provide daily, weekly, and monthly reports on status of current AR, denials, and coding issues to upper management.• Meet with departments as needed for process improvement on entering charges timely, resolving issues before they become denials, and to resolve issues holding up candidate for billing claims.Current Projects:• Denials Workgroup - Working with departments to reduce claim denials. Trending issues for each area based on a set of qualifiers applicable to each department. Setting a goal of denial reduction by 50% within one billing quarter.• Working with Epic Team to improve workflows with EHR system.

- Efficiently manages staff of 35 employees in different locations on and off campus- Manage processes for departmental coordination and continuation of patient care between departments and process implementation- Ongoing staff training for continuous quality improvement- Networking and team building with interacting departments- Point of service collections- Physician Order Compliance- Payer eligibility screening - Staffing schedules - Denials Workgroup – for monitoring and trending denials that are related to Patient Access Services (PAS).Current Projects:- Epic EHR implementation - Working with management team to streamline decentralized scheduling and move to a centralized scheduling department.- Working to improve prior authorizations process to reduce denials.Achievements:- Reduced authorization claim denials by 97% in 2 months (total savings of $384,000/mo on average).- Prevented $1.5 million in both soft and hard denials in one month by implementing strategic monitoring plan.

- Efficiently manage staff of 19 employees in different locations on campus- Manage processes for departmental coordination and continuation of patient care between departments and process implementation- Ongoing staff training for continuous quality improvement- Wait time reporting and monitoring for areas of improvement- Networking and team building with interacting departments- Point of service collections- Physician Order Compliance- Payer eligibility screening - Employee timecards / Staffing schedules - Denials Management Workgroup – for monitoring and trending denials that are related to Patient Access Services (PAS).Accomplishments: • Increased POS by 180% from prior year

• Prepare, compile, distribute, and analyze regular reports of denials and the financial impact• Project Management• Coordinator of day-to-day operations for denials contractor (Health Business Solutions (HBS)).• Identify sources of denials and the development of additional reports needed to investigate denial issues further.• RAC Audits / Non-RAC Audits• Managed care processes associated with appealing denied claim payments for both Hospital and Professional claims• Analyze data and generate detailed statistical reports and metrics.• Medical terminology including: CPT-4, ICD-9 & ICD-10, diagnosis and procedures coding, and HCPCS codingAccomplishments: • Reduced Recovery Audit Contractor dollars at risk from $11 million to $15,000 in one month.• Active member of the Quality Impact Committee

• Maintain Document Control Logs and Reports• File Structure Management• SharePoint Merging Projects• Digital Documents Management• Policy and Procedures (Writing and Maintaining)• Product Field Testing• Interpreting data• ISO 9000, 14001, & 18001 • Process Safety Management (PSM)

- External Quality Review Organization for the State of Texas Medicaid and CHIP HealthPlans- Medical Billing and Coding- Writing reports and summaries- Overseeing the quality, access, and timeliness of health care services provided byManaged Care Organizations (MCOs)- Designing clinical studies- Interpreting data- Monitoring project timelines

• Recruitment and Staffing Process• Interviewing Applicants• Company Credit Card Processing• Processing monthly reports• Arranging and processing travel• Customer Service• Budget Management• Purchasing and Invoicing