Experience

Devoted Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Provider Network Manager

  • May 2022 - Present

  Manage Risk PCP accounts for Martin, St. Lucie and Indian River Counties. Manage Risk PCP accounts for Martin, St. Lucie and Indian River Counties.



Centene Corporation

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Provider Network Specialist

  • Dec 2019 - May 2022

  Non-Risk PCPs and Medical Specialists Non-Risk PCPs and Medical Specialists



AmeriHealth Caritas

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Claims Research Analyst

  • 2016 - 2019

  Maintained Physicians and/or Hospital data and provider reimbursement set up, and addressed provider/state inquiries as it related to claim payment issues also facilitating and investigating cross-departmental issue resolution as they related to provider claim reimbursement. Met weekly with providers to discuss and resolve issue with contracting, agreements, claims, and provider set-up. Provided root cause and problem analysis for provider related issues and Worked with management to track… Show more Maintained Physicians and/or Hospital data and provider reimbursement set up, and addressed provider/state inquiries as it related to claim payment issues also facilitating and investigating cross-departmental issue resolution as they related to provider claim reimbursement. Met weekly with providers to discuss and resolve issue with contracting, agreements, claims, and provider set-up. Provided root cause and problem analysis for provider related issues and Worked with management to track trends, investigate data integrity to facilitate process improvements, minimize denials and reduce reimbursement errors.

• Provider Claims Specialist

  • 2015 - 2016

  Provided professional courteous and timely response and resolution to all customer needs, which included provider phone calls or correspondence regarding benefit, eligibility, status, medical claims, and other provider issues. Reviewed and adjudicated claims based on provider and Health Plan contractual agreements and claims processing guidelines. Served as a Subject Matter Expert. Conducted cross training to staff as required. Demonstrated solid knowledge of Provider Service/Claim systems,… Show more Provided professional courteous and timely response and resolution to all customer needs, which included provider phone calls or correspondence regarding benefit, eligibility, status, medical claims, and other provider issues. Reviewed and adjudicated claims based on provider and Health Plan contractual agreements and claims processing guidelines. Served as a Subject Matter Expert. Conducted cross training to staff as required. Demonstrated solid knowledge of Provider Service/Claim systems, functions and team process. Demonstrated superior skill in dealing with provider issues/inquiries, team members, and co-workers..



New life Cardiovascular Care

• Glenside, PA

• Billing Supervisor

  • 2014 - 2015

  Ensured services rendered in the clinic were properly accounted for by auditing billing systems and managed all outstanding and unresolved accounts. Oversaw all coding and fee schedules sets and assisted with implementation of new processes and protocols. Processed and submitted electronic / paper claims for timely filing and managed all accounts receivable.Maintained current working knowledge of CPT, ICD-9, ICD-10 coding principles, government regulations, protocols and third-party… Show more Ensured services rendered in the clinic were properly accounted for by auditing billing systems and managed all outstanding and unresolved accounts. Oversaw all coding and fee schedules sets and assisted with implementation of new processes and protocols. Processed and submitted electronic / paper claims for timely filing and managed all accounts receivable.Maintained current working knowledge of CPT, ICD-9, ICD-10 coding principles, government regulations, protocols and third-party requirements regarding billing.Strategically planned methods to achieve operational goals and targets in billing department by identifying gaps, implementing new processes, and analyzing the results. Show less Ensured services rendered in the clinic were properly accounted for by auditing billing systems and managed all outstanding and unresolved accounts. Oversaw all coding and fee schedules sets and assisted with implementation of new processes and protocols. Processed and submitted electronic / paper claims for timely filing and managed all accounts receivable.Maintained current working knowledge of CPT, ICD-9, ICD-10 coding principles, government regulations, protocols and third-party… Show more Ensured services rendered in the clinic were properly accounted for by auditing billing systems and managed all outstanding and unresolved accounts. Oversaw all coding and fee schedules sets and assisted with implementation of new processes and protocols. Processed and submitted electronic / paper claims for timely filing and managed all accounts receivable.Maintained current working knowledge of CPT, ICD-9, ICD-10 coding principles, government regulations, protocols and third-party requirements regarding billing.Strategically planned methods to achieve operational goals and targets in billing department by identifying gaps, implementing new processes, and analyzing the results. Show less



Tristate Medical Billing

• Accounts Receivable Analyst

  • 2014 - 2014

  Handled all correspondence and call inquiries related to MV/or WC insurance or patient account, contacted insurance carriers, patients and other entities as needed to get maximum payment on accounts and identify issues or changes to achieve client profitability. Contacted companies with unpaid insurance claims to negotiate settlement of claims payment. Resolved claims discrepancies, entered denials, deductibles and computed amounts due. Handled all correspondence and call inquiries related to MV/or WC insurance or patient account, contacted insurance carriers, patients and other entities as needed to get maximum payment on accounts and identify issues or changes to achieve client profitability. Contacted companies with unpaid insurance claims to negotiate settlement of claims payment. Resolved claims discrepancies, entered denials, deductibles and computed amounts due.



Northeast Community Mental Health Center

• Philadelphia, PA

• Billing Coordinator

  • 2006 - 2013

  Coordinated and supported initiatives relative to evaluation, processing, and handling of insurance claims for an organization. Liaison between organization, its insurance provider and agents, claimants, and policy holders regarding status and eligibility for coverage for all relevant claims. Reviewed claims ensuring billing requirements were met, updated accounts as necessary, answered inquiries, and made recommendations for resolution. Directed and coordinated daily work assignments of 4… Show more Coordinated and supported initiatives relative to evaluation, processing, and handling of insurance claims for an organization. Liaison between organization, its insurance provider and agents, claimants, and policy holders regarding status and eligibility for coverage for all relevant claims. Reviewed claims ensuring billing requirements were met, updated accounts as necessary, answered inquiries, and made recommendations for resolution. Directed and coordinated daily work assignments of 4 employees and ensured adequate staffing levels. Show less Coordinated and supported initiatives relative to evaluation, processing, and handling of insurance claims for an organization. Liaison between organization, its insurance provider and agents, claimants, and policy holders regarding status and eligibility for coverage for all relevant claims. Reviewed claims ensuring billing requirements were met, updated accounts as necessary, answered inquiries, and made recommendations for resolution. Directed and coordinated daily work assignments of 4… Show more Coordinated and supported initiatives relative to evaluation, processing, and handling of insurance claims for an organization. Liaison between organization, its insurance provider and agents, claimants, and policy holders regarding status and eligibility for coverage for all relevant claims. Reviewed claims ensuring billing requirements were met, updated accounts as necessary, answered inquiries, and made recommendations for resolution. Directed and coordinated daily work assignments of 4 employees and ensured adequate staffing levels. Show less