Ensured all member complaints were addressed and categorized correctly.
Determined and confirmed member eligibility and benefits.
Obtained additional documentation required for case review and scanned all documents into secured image repository.
Limited outbound communication to members or providers.
Prioritized and organized tasks to meet CMS compliance deadlines.
Ability to meet established productivity, schedule adherence, and quality assurance standards.
Billing Clerk, 03/2009 to 10/2011 Carestl Health – Saint Louis, MO,
Responsible for medical records maintenance.
Managed all front desk duties such as; answered telephones, provided customer service assistance, assisted doctors with appointment scheduling and ordered supplies for all management and business office.
Processed all manual and electronically bills into DMH.
Verified patient medical eligibility prior to receiving medical services.
Updated all clients Payer Financial Forms.
Processed new patient information in company database(s).
Requested removal of SFPR and updated Payer Financial Forms from different agencies.
Opened/discharged clients electronically and manually for therapists to create proper billing.
Conducted weekly audits of providers notes to ensure billing hours and clients were recorded correctly.
Data Entry Clerk, 10/2008 to 01/2009 Canon Business Process Services – Southfield, MI,
Responsible for all front desk duties such as; telephones, FedEx mail and assisted sales representatives.
Responsible for managing data base list for all body and mechanical shops.
Provided assistance VP with business travel arrangements; such as booking flights and making hotel accommodations.
Medical Records Clerk, 03/2008 to 06/2008 Grane – Aurora, CO,
Prepared all Plan of Care and Revisions for Physician's sign-off.
Conducted all patient chart audits and filings.
Hands-on knowledge in processing payroll for clinical staff.
Medical Records Clerk, 11/2007 to 03/2008 Grane – Mount Pleasant, PA,
Responsible for verifying patient information (PI) including duplicate records.
Merged PI in the system and consolidated patient documents.
Expert in using the following systems; Auditor, MediTech and IDX.
Data Entry Clerk, 10/2006 to 01/2007 Canon Business Process Services – Sunnyvale, CA,
Responsible for entering client and patient's data into the database system.
Updated & reviewed patient's medical information in computer database.
Completed all clients billing and daily medical billers inquiries.
Customer Service Associate
Teacher Supplies, 01/2005 to 01/2006 – City, STATE,
Responsible for store operations, including loss prevention, in-store audits and cash handling.
Developed an effective style in dealing with the educators in both sales and client relations.
Handled walk-in inquires including telephone requests and processed all orders in a timely fashion.
Work History
Utilization Management Specialist, 03/2015 to Current St Joseph Heritage Healthcare – Anaheim, CA
Verifying requests for pre-authorizations by communicating directly with nurse case managers.
Reviewing claims, insurance and rejection orders to determine the type of authorization required.
Obtaining and managing all necessary appeal's information, including documents and orders on behalf of patients.
Tracking and recording all communication between insurance carriers and facility representatives.
Working with referral specialists to assist in running referral reports and serving as a backup to the process workflow.
Generating outbound correspondence for patients and or providers.
Prioritizing and organizing tasks to meet CMS compliance deadlines.
Ability to meet establishing productivity, scheduling adherence, and quality assurance standards.
Appeals Coordinator, 12/2012 to 01/2015 United Health Group – Cypress, CA
Ensured all member complaints were addressed and categorized correctly.
Determined and confirmed member eligibility and benefits.
Obtained additional documentation required for case review and scanned all documents into secured image repository.
Limited outbound communication to members or providers.
Prioritized and organized tasks to meet CMS compliance deadlines.
Ability to meet established productivity, schedule adherence, and quality assurance standards.
Billing Clerk, 03/2009 to 10/2011 Harbor View Community Services – Long Beach, CA
Responsible for medical records maintenance.
Managed all front desk duties such as; answered telephones, provided customer service assistance, assisted doctors with appointment scheduling and ordered supplies for all management and business office.
Processed all manual and electronically bills into DMH.
Verified patient medical eligibility prior to receiving medical services.
Updated all clients Payer Financial Forms.
Processed new patient information in company database(s).
Requested removal of SFPR and updated Payer Financial Forms from different agencies.
Opened/discharged clients electronically and manually for therapists to create proper billing.
Conducted weekly audits of providers notes to ensure billing hours and clients were recorded correctly.
Data Entry Clerk, 10/2008 to 01/2009 Assured Performance Network – Irvine, CA
Responsible for all front desk duties such as; telephones, FedEx mail and assisted sales representatives.
Responsible for managing data base list for all body and mechanical shops.
Provided assistance VP with business travel arrangements; such as booking flights and making hotel accommodations.
Medical Records Clerk, 03/2008 to 06/2008 Interim Healthcare – Orange, CA
Prepared all Plan of Care and Revisions for Physician's sign-off.
Conducted all patient chart audits and filings.
Hands-on knowledge in processing payroll for clinical staff.
Medical Records Clerk, 11/2007 to 03/2008 St. Jude's Medical Center – Fullerton, CA
Responsible for verifying patient information (PI) including duplicate records.
Merged PI in the system and consolidated patient documents.
Expert in using the following systems; Auditor, MediTech and IDX.
Data Entry Clerk, 10/2006 to 01/2007 Solutions Health Care Management – La Palma, CA
Responsible for entering client and patient's data into the database system.
Updated & reviewed patient's medical information in computer database.
Completed all clients billing and daily medical billers inquiries.
Customer Service Associate
Teacher Supplies, 01/2005 to 01/2006 – Anaheim Hills, CA
Responsible for store operations, including loss prevention, in-store audits and cash handling.
Developed an effective style in dealing with the educators in both sales and client relations.
Handled walk-in inquires including telephone requests and processed all orders in a timely fashion.
Education
AA: , Expected in 2004 Fullerton College - Fullerton, CA GPA: in progress
HS Diploma: , Expected in 2003 Western High School - Anaheim, CA GPA:
Summary
Highly experienced in reimbursement and claims processing, and applying billing and coding principles consistent with government regulatory standards (Medicare, Medicaid, Medi-Cal, HMO & PPO). Closely monitor authorization processes for the practice, with special focus on clarity of each module. Skilled in processing referrals based upon insurance plans and following up on outstanding authorizations and accurately documenting events in Electronic Medical Records (EMR) systems.
Member eligibility and benefits coverage experience with all major payers' plans such as UHC, Aetna, Cigna, Blue Cross Blue Shield, Scan and Healthnet
Microsoft Office (Word, Excel, Power Point & Outlook)
Backup, Recording
Benefits, Sales
Billing, Scheduling
Cash handling, Telephone
CMS, Telephones
Client, Travel arrangements
Clients, Plan of Care
Client relations, Type
Customer service, Workflow
Data Entry
Data base
Database
Documentation
Fashion
Financial
Forms
Image
Insurance
Loss prevention
Notes
Managing
Mechanical
Medical records maintenance
MediTech
Excel
Mail
Microsoft Office
Office
Outlook
Power Point
Word
Organizing
Processing payroll
PC Skills
Coding
Progress
Quality assurance
Receiving
Skills
Healthcare Tools: Allscripts/Touchworks, Providers Portals, Appeals Portals, IDX, CalOptima Web, CHOC Health Alliance Web, Medical/Medicare Portals. Microsoft Office (Word, Excel, Power Point & Outlook),
Backup, Benefits, Billing, cash handling, CMS, client, clients, client relations, customer service, Data Entry, data base, database, documentation, fashion, Financial, Forms, image, Insurance, loss prevention, notes, managing, mechanical, medical records maintenance, MediTech, Excel, mail, Microsoft Office, office, Outlook, Power Point, Word, organizing, processing payroll, PC Skills, Coding, progress, quality assurance, receiving, recording, sales, scheduling, telephone, telephones, travel arrangements, Plan of Care, type, workflow
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