Claims And Appeals Specialist Resume Example Spine Associates Richard Francis Md

CLAIMS AND APPEALS SPECIALIST

Professional Summary

Medical Claims and Appeals Specialist with over 7 years of successful experience in accurately processing claims and executing appeal protocols accordingly, within the required timeframe. Recognized consistently for performance excellence and contributions to success by my seniors. Strengths in time management and transparent communication backed by training in medical office responsibilities.

Skills

Organization and Time management
Critical thinking
Collaboration
Excellent work ethic
Teambuilding

Customer Service
Account management
Documentation abilities
Conflict resolution
Responsible

Work History

Claims and Appeals Specialist04/2019 to Current
Spine Associates Richard Francis Md – Little Rock, AR

Prepared insurance claim forms or related documents and reviewed for completeness.
Reviewed outstanding requests and redirected workloads to complete projects on time.
Prevented financial delinquencies by working closely with managers to resolve billing issues before becoming unmanageable.
Analyzed complex Explanation of Benefits forms to verify correct billing of insurance carriers.
Delivered timely and accurate charge submissions utilizing HST Pathways, eClinicals, and Athena software.
Followed up on legal claims.
Maintained current accounts through aged revenue reporting.
Communicated with insurance providers to resolve any denied claims and resubmit.
Trained new employees on multiple medical billing programs and data entry software.
Filed and updated patient information and medical records.
Transferred balances to correct payers.
Liaised between patients, insurance companies and billing office.
Researched and followed up on denied insurance claims.
Gathered information from multiple sources to simplify billing and organize accounts.
Verified proper ICD-9 coding on claims.
Processed insurance company denials by auditing patient files, researching procedures and diagnostic codes to determine proper reimbursement.
Submitted electronic and paper claims to insurance companies including Medicare and Medicaid to collect medical payments.
Adhered to established standards to safeguard all patients' health information.
Devised new methods to make workflows more efficient and brought suggestions to the attention of my immediate supervisors.
Reviewed outgoing bills for eligibility and accurateness.
Communicated effectively with staff, including members of operations, finance and clinical departments.
Maintained confidentiality of patient finances, records and health statuses.
Tracked all pending authorizations to resolve discrepancies and avoid revenue loss.
Communicated verification and authorization status updates with Pre-Certification department to facilitate decision-making for patient admissions and insurance coverage.
Created spreadsheets using Microsoft Excel for daily, weekly and monthly reporting.
Used Microsoft Word and other software tools to create documents and other communications.
Reviewed questionable claims by conducting agent and claimant interviews to correct omissions and errors.
Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
Evaluated original investigation reports and documents to resolve secondary concerns.
Identified, researched and resolved billing variances to maintain system accuracy and currency.
Worked effectively with medical payers such as Medicare, Medicaid, commercial insurances to obtain timely and accurate payments.
Generated accounts payable reports for management review to aid in financial and business decision making.

Medical Billing and Collections Specialist04/2018 to 04/2019
Universal Surgical Partners – Houston, TX

Printed and reviewed monthly patient aging report and solicited overdue payments.
Accurately posted and sent out all medical claims.
Determined prior authorizations for medication and outpatient procedures.
Applied charges and updated patient records by using Mahler and Medisoft software.
Maintained and updated collections tracking spreadsheet to help organize payment information.
Trained new employees on multiple medical billing programs and data entry software.
Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
Located errors and promptly refiled rejected claims.
Posted and adjusted payments from insurance companies.
Communicated with patients for unpaid claims for HMO, PPO and private accounts and delivered friendly follow-up calls for proper payments to contracts.
Communicated effectively and extensively with other departments to resolve claims issues.
Precisely evaluated and verified benefits and eligibility.
Submitted electronic and paper claims to insurance companies including Medicare and Medicaid to collect medical payments.
Researched and followed up on denied insurance claims.
Prevented financial delinquencies by working closely with managers to resolve billing issues before becoming unmanageable.
Prepared insurance claim forms or related documents and reviewed for completeness.
Tracked all pending authorizations to resolve discrepancies and avoid revenue loss.
Communicated verification and authorization status updates with Pre-Certification department to facilitate decision-making for patient admissions and insurance coverage.
Used Microsoft Word and other software tools to create documents and other communications.

Account Manager11/2014 to 04/2018
Altus Infusion – Pearland, TX

Addressed problems with accounting, billing and service delivery to maintain and enhance client satisfaction.
Scheduled appointments with applicants to gather information and explain benefits processes.
Followed guidelines when reviewing applicant data to determine eligibility for economic assistance.
Assured timely verification of insurance benefits prior to patient procedures or appointments.
Made contact with insurance carriers to discuss policies and individual patient benefits.
Contacted hospitals to confirm patients medical histories and prevent inaccurate diagnoses and treatments.
Answered phone calls and messages for the medical facility, scheduling appointments and handling patient inquiries.
Referred delinquent accounts to collections department or outside resources.
Maintained and updated collections tracking spreadsheet to help organize payment information.
Determined prior authorizations for medication and outpatient procedures.
Precisely evaluated and verified benefits and eligibility.
Submitted electronic and paper claims to insurance companies including Medicare and Medicaid to collect medical payments.
Analyzed medical records to satisfy insurance company mandates.

Education

Medical Assistant Certification: Clinical Assistant11/2008Texas Medical School Of Business- Houston, TX

Resume Overview

Companies Worked For:

Spine Associates Richard Francis Md
Universal Surgical Partners
Altus Infusion

School Attended

Texas Medical School Of Business

Job Titles Held:

Claims and Appeals Specialist
Medical Billing and Collections Specialist
Account Manager

Degrees

Medical Assistant Certification : Clinical Assistant 11/2008

Claims and Appeals Specialist Resume Example

Resume Score: 80%

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