Appeals Analyst Resume Example Bluecross Blueshield Of North Carolina

APPEALS ANALYST

Summary

Revenue-driven professional with proven expertise in all aspects of the healthcare revenue cycle, complemented with background in Finance. Able to understand business needs with the fundamentals of billing/coding accuracy, time management and their effect on cash flow. Demonstrate a sense of ownership for all work with the goal to meet and maintain performance standards. Driven to retain and apply the useful knowledge and skills necessary to further my career as an accomplished and effective professional.

Skills

Certified Professional Coder
Proficient knowledge of ICD-10, ICD-9, CPT, HCPCS codes and medical terminology
Extensive knowledge on medical claim coding, billing procedures and insurance obligations
Systems: IDX, Centricity, Medisoft, EMR, CareRadius, Macess, PowerMHS
Proficient in MS Word, Excel, Power Point and Outlook.

Experience

Appeals Analyst
October 2014 to August 2015BlueCross BlueShield of North Carolina － Chapel Hill, NC

Provide coding appeals support by reviewing, researching, investigating using established criteria of professional, inpatient or outpatient, facility services.
Review appropriate regulatory references to identify/substantiate medical supplies, drugs/medicine, diagnosis, procedures and modifiers that support services billed.
Utilize the most up to date documentation /guidelines in responding to appeals.
Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.
Takes initiative to query the physician for documentation or clarification to justify services.
Create, maintain and track reports in relation to performance.
Handle appeals and/or telephone/email inquiries related to determination of appeal.

BILLING REPRESENTATIVE
August 2012 to May 2013Winthrop University Hospital － Bethpage, NY

Processed claims for twelve physicians inpatient and outpatient.
Researched on updates with payable procedures and diagnosis codes.
Submitted all required documentation with each claim including workers compensation and no fault.
Verified the correct billing format, assigning the proper modifiers from operative reports.
Clarified medical necessity with physicians as per individual payers guidelines.
Prepared daily, weekly and month end reports and payment reconciliations.
Processing 60 to 90 claims daily while maintaining 95% accuracy and achieving productivity goals.

MEDICAL BILLER CODER
October 2010 to August 2012ProHealth Care Associates － Lake Success, NY

Division of Cardiology and Internal Medicine.
Billing and collections for five physicians.
Obtained pre-certifications from health plans, wrote letters of medical necessity, followed up on cases in medical review and handled denials/appeals from insurance companies including Medicare.
Prepared code review audit reports for cost control and better business processes.
Negotiate and enforce collections to recover funds on delinquent accounts.
Staff training and supervision.
Researched, appealed and reimbursed 90% by individual payers on audit reports.

ASSISTANT ADMINISTRATOR
May 2010 to July 2010Horizon BCBS － Newark, NJ

Recruited for marketing project for big companies to be credentialed.
Supported the department by assisting with administrative and special projects as assigned by the manager.
Created, developed and maintained databases related to departmental activities and special projects.

MEDICAL BILLER COLLECTOR
August 2009 to April 2010DR, TASNEEM SHAMIM － SOMERSET, NJ

A single physician specialty practice.
Independently managed paper and electronic primary, secondary and tertiary claim submissions.
Settled years of open balances in patients' accounts.
Coordinated surgery bookings and medical records/clearance from other providers.
Developed and implemented policies and procedures for payment posting ensuring patient accounts are complete and ready for billing charge entry.
Grew practice to a profitable business through effective policies and work procedures.

SERVICE OFFICER/BACKUP OPERATIONS MANAGER
September 2006 to February 2008Citibank N. A － Edison, NJ

Delivered optimal customer experience by greeting, servicing and referring customer.
Served as primary point of contact to facilitate and expedite problem resolution.
Assisted in managing and auditing Financial Associates to ensure client financial transactions were executed.
Adhere to operational controls, including legal, corporate, and regulatory procedures to ensure the safety and security of customer and bank assets including opening and closing of business day and wire transfers of large funds.
Worked with the financial center operations manager to maintain a solid foundation by pulling reports on a daily basis helping to improve operational control, mitigate losses and ensure a consistent and superior client experience.

Education and Training

Bachelor of Science : Finance, Jan 2009St. Johns University － Jamaica, NYFinance

Activities and Honors

American Academy of Professional Coders (AAPC) American Health Information Management Association (AHIMA) 3

Skills

accounts receivables, administrative, audit reports, auditing, balance, Billing, business processes, Cardiology, closing, cost control, CPT, client, databases, diagnosis, documentation, email, Staff training, Financial, funds, ICD-10, ICD-9, insurance, Internal Medicine, legal, letters, managing, marketing, medical terminology, Medisoft, Excel, Outlook, Power Point, MS Word, policies, problem resolution, coding, researching, safety, supervision, surgery, telephone

Resume Overview

Companies Worked For:

BlueCross BlueShield of North Carolina
Winthrop University Hospital
ProHealth Care Associates
Horizon BCBS
DR, TASNEEM SHAMIM
Citibank N. A

School Attended

St. Johns University

Job Titles Held:

Appeals Analyst
BILLING REPRESENTATIVE
MEDICAL BILLER CODER
ASSISTANT ADMINISTRATOR
MEDICAL BILLER COLLECTOR
SERVICE OFFICER/BACKUP OPERATIONS MANAGER

Degrees

Bachelor of Science : Finance , Jan 2009

Appeals Analyst Resume Example

Resume Score: 90%

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