Experience

Flagler Health+

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

• Revenue Cycle Administrator

  • Dec 2022 - Present

• Director Of Managed Care

  • Jun 2017 - Jan 2023

  DIRECTOR OF MANAGED CARE, 2019-PresentOversight of all aspects of managed care and direct revenue contract management including negotiation, analysis interpretation, implementation, maintenance of the contract’s performance, and payer relations. Develop new and existing relationships with third party payers to ensure competitive reimbursement rates and consistent contract language through the revenue cycle operations. Oversee payer credentialing, charge master, and manage denials and appeals. Identify trends and compliance within contract parameters. REVENUE INTEGRITY MANAGER, 2017-2019Manage team responsible for managing government and third-party payor audits, including RAC, MAC, MIC, and charge audits. Analyze and interpret managed care contracts; ensure professional and facility billable charges are captured and coded completely and accurately. Research billing and coding requirements, evaluate and integrate new technology and formularies. Establish protocols, policies and procedures, and training materials. Participate in internal and external contracted payor discussions and negotiations regarding clinical coding and charging standards.



UF Health Jacksonville

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

• Revenue Integrity Manager

  • 2014 - May 2017

  Oversaw team researching and analyzing reimbursement methodologies, revenue cycle management, and health information systems. Audited charges against reimbursement and records documentation, and resolved issues with fiscal intermediaries. Coordinated and led multi-department projects, provided education and direction on current and emerging regulations, and executed initiatives in conjunction with Director of Patient Financial Services. Expertise in Epic HB Resolute billing and charging. Oversaw team researching and analyzing reimbursement methodologies, revenue cycle management, and health information systems. Audited charges against reimbursement and records documentation, and resolved issues with fiscal intermediaries. Coordinated and led multi-department projects, provided education and direction on current and emerging regulations, and executed initiatives in conjunction with Director of Patient Financial Services. Expertise in Epic HB Resolute billing and charging.



C2C Solutions

• India
• Staffing and Recruiting
• 1 - 100 Employee

• Project Analyst-QIC PDRC

  • 2009 - 2014

  RECONSIDERATION PROJECT ANALYST, 2009Present Audit, oversight, anti-fraud and abuse monitoring for Medicare claims reimbursements. Review and write reconsideration decisions in support of determination after reviewing case records and claims. Conduct on-the-record second level appeals in line with polices. Prepare releasable documents in compliance with Privacy Act and submit decisions within deadlines. Research Medicare reimbursement policies and regulations for multiple service types including DME, Parts A and B, and CPT and HCPCS coding. Resolved payment disputes based on medical records reviews. Reviewed physician determinations and prepared correspondence to Medicare beneficiaries/representatives, healthcare providers and physicians. Assured compliance with regulatory, contractual and accreditation entities. Maintained strict adherence to confidentiality and security policies and procedures. Create SQL reports.



First Coast Service Options, Inc.

• United States
• Hospitals and Health Care
• 200 - 300 Employee

• Reimbursement Auditor

  • 2008 - 2009

  Reviewed data of all source documents required for insurance billing reimbursement. Monitored information to ensure timely, error-free claims processing for all payers. Identified error trends and conducted training to improve claim quality. Ensured compliance with policies and procedures. Maintained and kept abreast of changes in Medicare Conditions of Participation, Coverage of Services rules, PPS reimbursement regulations, and insurance reimbursement principles. Reviewed data of all source documents required for insurance billing reimbursement. Monitored information to ensure timely, error-free claims processing for all payers. Identified error trends and conducted training to improve claim quality. Ensured compliance with policies and procedures. Maintained and kept abreast of changes in Medicare Conditions of Participation, Coverage of Services rules, PPS reimbursement regulations, and insurance reimbursement principles.



Saint Vincent's Medical Center

• Recruiter/Internship

  • 2008 - 2008

  Developed, implemented, and coordinated recruitment action plan to fill vacant health and nursing positions. Reviewed applications and resumes, conducted interviews, and referred qualified applicants to department managers. Monitored and tracked applicant submissions for employment or transfers, ordered background screening and testing required prior to start date. Represented hospital at career days, job fairs, and conventions. Created recruitment materials for distribution. Coordinated travel arrangements and assisted with relocation cost reimbursement.



Prudential/Aetna Insurance

• Recalculation/Auditor/Claims Examiner

  • 1992 - 2001

  Reviewed, audited, and monitored accuracy of high-dollar medical claims to ensure proper reimbursement. Calculated hospital and medical claims, verified codes used for diagnosis, treatment and procedures according to correct classification for patient encounters. Entered data and processed claims into database. Responded to customer inquiries and complaints and negotiated resolution. Reviewed, audited, and monitored accuracy of high-dollar medical claims to ensure proper reimbursement. Calculated hospital and medical claims, verified codes used for diagnosis, treatment and procedures according to correct classification for patient encounters. Entered data and processed claims into database. Responded to customer inquiries and complaints and negotiated resolution.