Experience

Advanced Urology

• United States
• Medical Practices
• 100 - 200 Employee

• Auditor/Claims editor

  • Apr 2021 - Present

  Snellville, Georgia, United States



Pilot Catastrophe Service

• United States
• Insurance
• 700 & Above Employee

• Field Digital Inspector Contractor

  • Sep 2017 - Oct 2017

  Mobile, Alabama Area • Provided customer service • Assisted inside adjuster • Imaged pictures and measurements of roof and property damage



SavaSeniorCare Administrative Services LLC

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

• Medical Records Coordinator Contractor

  • Oct 2016 - May 2017

  Greater Atlanta Area • Scanning of medical documentation to produce digital copies of documents for retention and review. • Organizing scanned documents on various local and/or network drives. • Inventories and organizes Medical records documentation for record retention. • Upon request may be required to scan documents. • Prepare documentation for on-site and long-term storage. • Contact providers validating contact information as requested. • Maintains file organizational system. • Back-up… Show more • Scanning of medical documentation to produce digital copies of documents for retention and review. • Organizing scanned documents on various local and/or network drives. • Inventories and organizes Medical records documentation for record retention. • Upon request may be required to scan documents. • Prepare documentation for on-site and long-term storage. • Contact providers validating contact information as requested. • Maintains file organizational system. • Back-up for claims coordinator calls to RACs and MACs for reconsideration of payment. Show less



HEALTH MANAGEMENT SYSTEMS

• United States
• 1 - 100 Employee

• Development Specialist II

  • Nov 2012 - Jan 2014

  Reviewed multi-state Medicaid claim payments (inpatient hospital and skilled nursing, outpatient/ambulatory, nursing, physician, ambulance, and lab services) to identify underpayments/overpayments. Researched local billing and reimbursement policies, client reimbursement practices to develop and configure overpayment algorithms. Scenario development Supported IT with the developing and implementing of technological improvements to reduce payment errors. Worked with internal… Show more Reviewed multi-state Medicaid claim payments (inpatient hospital and skilled nursing, outpatient/ambulatory, nursing, physician, ambulance, and lab services) to identify underpayments/overpayments. Researched local billing and reimbursement policies, client reimbursement practices to develop and configure overpayment algorithms. Scenario development Supported IT with the developing and implementing of technological improvements to reduce payment errors. Worked with internal operations and clinical teams to develop and implement review/audit/recovery protocols and internal review guidelines as well as development. Show less



Amerigroup

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

• Business Analyst II

  • Jan 2008 - Jan 2012

  Researched Medicaid claims payment and billing guidelines, audit results, and provider contracts to determine overpayments and underpayments. Expedited refund requests from healthcare providers. Processed and reviewed daily provider refund checks for calculation accuracy. Interpreted policy provisions to accurately process Overpayment adjustments. Reviewed variances and interfaced with Accounting, Information Systems, and other departments to resolve claim audit issues resulting in… Show more Researched Medicaid claims payment and billing guidelines, audit results, and provider contracts to determine overpayments and underpayments. Expedited refund requests from healthcare providers. Processed and reviewed daily provider refund checks for calculation accuracy. Interpreted policy provisions to accurately process Overpayment adjustments. Reviewed variances and interfaced with Accounting, Information Systems, and other departments to resolve claim audit issues resulting in underpayments and/or overpayments. Set-up payment plans for providers for overpayments. Provided leads for overpayments for future reimbursements projects. Interfaced with outside vendors for accuracy of audits and corrections.

• Recovery Audit Analyst

  • 2008 - 2012

  • Researched Medicaid claims payment and billing guidelines, audit results, and provider contracts to determine overpayments and underpayments. • Expedited refund requests from healthcare providers. • Processed and reviewed daily provider refund checks for calculation accuracy. • Interpreted policy provisions to accurately process Overpayment adjustments. • Reviewed variances and interfaced with Accounting, Information Systems, and other departments to resolve claim audit issues… Show more • Researched Medicaid claims payment and billing guidelines, audit results, and provider contracts to determine overpayments and underpayments. • Expedited refund requests from healthcare providers. • Processed and reviewed daily provider refund checks for calculation accuracy. • Interpreted policy provisions to accurately process Overpayment adjustments. • Reviewed variances and interfaced with Accounting, Information Systems, and other departments to resolve claim audit issues resulting in underpayments and/or overpayments. • Set-up payment plans for providers for overpayments. • Provided leads for overpayments for future reimbursements projects. • Interfaced with outside vendors for accuracy of audits and corrections.



Blue Cross Blue Shield of Georgia

• United States
• Insurance

• Medical Claims Auditor

  • Jan 2001 - May 2006

  Greater Atlanta Area • Provided cost-savings services for a major self-insured client by reviewing financial quality control audits of claims, in compliance with medical coding guidelines, healthcare provider contractual provisions, HIPAA/ERISA mandates, and group health plan policies/provisions. • Responsible for pre and post payments and adjudication audits of high dollar claims for all lines of business • Ensure claims payment accuracy by verifying various aspects of the claim… Show more • Provided cost-savings services for a major self-insured client by reviewing financial quality control audits of claims, in compliance with medical coding guidelines, healthcare provider contractual provisions, HIPAA/ERISA mandates, and group health plan policies/provisions. • Responsible for pre and post payments and adjudication audits of high dollar claims for all lines of business • Ensure claims payment accuracy by verifying various aspects of the claim including eligibility, system errors and pricing, pre*authorization, and medical necessity. • Completes and maintain detailed documentation of audits which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis • Provided feedback during monthly team meetings on processing errors • Identify quality improvement opportunities and initiates basic requests related to coding or system issues where applicable. • Supported corporate training/educational development efforts by providing leadership and training to an assigned team within the Claims Department, providing audit results to educate team members on policies and procedures monthly. • Supported departmental operations as a research specialist for special projects for management.

• Claims Lead

  • Jan 1990 - Jan 2001

  Served as a team lead for Claims Specialists by providing training, guidance, and technical expertise. Audited reimbursement requests on claim payment requests exceeding $2000 according to established procedures, approving or denying such claims accordingly. Performed assigned special projects.