High-energy individual successful in building and motivating dynamic teams with 6 years in the Medical/Healthcare industry & 5 years of managerial experience. Proven ability to turn around ineffective workflows and implement better business practices.
● Responsible for monitoring the company's Worker Compensation program and manage the OSHA Log for the Boston station
● Work closely with the Safety & Quality Manager to ensure that the Claim Reduction Program and Standard Operating Procedures are being followed & contribute to procedural and operational audits
● Monitor days out of work log & follow up with what can be done to get the injured employee back to work as soon as possible
● Monitor claims cost & update spreadsheet with Reserve increase/decrease
● Participate in the Monthly Safety Committee Meeting and posted safety and near misses bulletins
● Work closely with company's Adjuster to put procedures in place to help cost control
● Provided effective and timely coordination of communication with clients, claimants and other appropriate parties throughout the claim adjustment process
● The point of contact for 3 business lines for all documentation regarding incident, includes internal safety notify and investigation details, as well as any health information relevant to the claim from outside medical providers and treatment notes. Health information is limited to medical related to the injury
● Responsible for daily management of account receivable process and follow up in the billing system, including daily screening and correction of claims for accuracy for the surgical department
● Review, correct and completion of edit queues weekly for the particular insurance (s) assigned for the surgical department
● Follow-up on pending claims, this includes following up with the insurance company, document the findings and gather and send the necessary documentation to process the claims.
● Responsiblefor the appeals process, which included researching payer websites, pulling of documentation such as EOB's, requesting medical records, and reviewing registration/eligibility and benefits, as well as documenting all work performed on the patient invoice.
● Customer Service calls. Responsible for handling customer service calls and demonstrate excellent customer service skills, listening, problem solving, professionalism, etc
● Handle confidential information with accordance with HIPAA standards.
● Conducts forensic accounting on account balances that have been open for over a year or more by reviewing invoices history to determine payments/retractions and inform management of discoveries for swift resolution
● Provide Management with analytical data and trend analysis that occur within insurance carriers
● Processed medical referrals in a timely manner to include but not limited to completion of service request (direct and prior authorization referrals) forms manually and/or through EMR
● Faxed service requests to Utilization Management department for approvals
● Processed and send requests to the specialty offices for processing and scheduling of patient appointment
● Notified patients of scheduled appointments by phone, in person with appointment information or by mail and documented in the patients chart
● Obtained insurance information from patients, which included collecting co-payments and self-paid balances from patients
● Followed up with specialist offices on pending/outstanding patient appointments and documented in patients chart
● Processed consult reports that were received, completed and close referrals in the patient's charts
● Reported referral problems to providers, supervisor and administrator
● Reviewed referral log daily and provided weekly progress to supervisor and administrator
● Worked closely with outside vendors to establish and build effective working relations
● Worked closely with Utilization Management, Provider Services and Contracting Department
● Single-handily managed, worked, maintained, and closed a two year backlog of the clinic's referrals, denials and authorizations within the first year of employment
● Familiar with Medicare Advantage plans
● Provided call coaching, constructive feedback and direction to staff to ensure consistent customer service
● Demonstrated mastery of customer service call script within specified time frames
● Provided technical expertise to staff and handled elevated calls
● Explained training methods and teaching skills sufficient to conduct continuing education for staff development.
● Monitor overall quality, education, completeness and accuracy of medical record documentation
● Explained coding and documentation concepts, guidelines, and clinical terminology
● Ability to establish and maintain strong verbal and written communication with providers
● Conducted monthly audits on staff to ensure quality of care and customer service is giving
● Responded and resolved members inquires, complaints, included incoming calls from outside Medicare state department inquiring about policy and procedures, concerns of benefits as well as claims discrepancies ● Possess understanding of call center metrics and best practices to achieve optimal performance
● Monitor Finesse and communicated with Work Force Management to improve agent productivity
● Specialization in Management
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