Arlynda Gibson
Pflugerville
Summary
To obtain a position with a healthcare organization that is challenging and growth oriented.
Professional with strong background in claims management and conflict resolution. Skilled in streamlining processes, ensuring compliance, and fostering effective communication between stakeholders. Known for strong teamwork, adaptability, and achieving results under changing conditions. Highly competent in policy analysis, customer service, and problem-solving, bringing reliability and results-driven approach to every task.
Overview
15
15
years of professional experience
Work History
Claims Liaison II
Centene Corp
05.2023 - 04.2025
- Lead the Claims Support Services Operational meetings with various departments and the Pricing Committee
- Ensure the documentation, tracking and resolution of all plan providers’ billing and payment issues
- Research and resolve complex verbal and written providers’ claims inquiries
- Identify authorization issues and trends and recommend action plan for resolutions
- Direct and educate Provider Services and Relations with the claims reprocessing notification, utilizing knowledge of provider billing and claims processing
- Analyze trends in claims processing issues, identify and quantify issues, and implement at changes to work processes
- Identify providers experiencing many claims issues or with the potential to develop claims issues and proactively work to eliminate barriers for accurate and timely claims processing
- Identify potential and documented eligibility issues and notify applicable departments to resolve
- Communicate any claims system or procedural changes in a timely manner
- Meet with providers to discuss claims payment policies and procedures and resolve claims issues as needed
- Identify needs and conduct additional claims training to internal departments
- Document all provider inactions, monitor queues and make any necessary changes
- Review and ensure provider additions, changes and terminations are complete
- Run and analyze claims reports regularly through provider information systems
Reconciliation Lead
Centene Corp
09.2021 - 05.2023
- Work with Patients and Families to resolve grievances and complaints.
- Provide technical support to staff and provide ongoing training.
- Operate as a team lead/support for Reconciliation Coordinators and guide, support on daily authorizations, reports, and claims.
- Delegate duties, coordinate daily work, and provide training and authorization updates as they relate to reconciliation coordinators.
- Generate daily authorizations error report, review, correct, and reconcile to pay claims.
- Identify trends and patterns by error and provide feedback for staffing training purposes and/or system configuration improvement.
- Conduct investigation related to appropriate coding practices, diagnosis and level of care (LOA) allocation and billing by hospitals in comparison of authorized services.
- Investigate pending claims for authorization, conduct timely review of authorization module and reconcile for claim payment.
- Identify and process retrospective authorizations for services not requiring medical review.
- Enter notes into the claims system (CCMS) system for appropriate claims payment for single case agreements generated by Medical Director
Claims Auditor Lead
Wellpath
09.2018 - 09.2021
- Perform audit of claims received because of out of facility services with the highest degrees of accuracy and timeliness. Confirms correctness of claim amounts, eligibility and events
- Understand and reference Wellpath provider contracts, leased network contracts, and other relevant artifacts as they relate to claims audit and appeals.
- Ensure compliance with Wellpath’s claims standards, audit criteria, and other policies and procedures.
- Perform the Wellpath Claims Appeals functions including claims audits, high dollar review, contract compliance and response narratives.
- Reports and tracks audit findings, summarizes problem areas and identifies potential solutions, remedies and controls.
Claims Research Specialist
Wellpath
07.2017 - 07.2018
- Received calls from providers and customers dealing with medical claims issues.
- Document each call in salesforce review/track all correspondence received.
- Resolved all claims issues by performing all necessary research and communicating solutions in response to customer.
- Triage issues and determine for cross-functional department involvement in resolving billing claims issues.
- Researched and answered questions from providers, customers or sites regarding claims payment, eligibility and authorizations for services.
- Performed other duties as assigned.
Insurance Follow-Up Billing Specialist
Medical Billing Management
03.2016 - 04.2017
- Answered patient calls, assisted with resolving account issues, and took payments.
- Responded to all correspondence from insurance payers and patients.
- Keyed medical charges and submitted clean claims to various insurance companies.
- Followed up on aging claims and claim denials.
- Communicated effectively with doctor’s office to ensure that required documentation is present.
- Resolved errors to claims that needed to be fixed to help get the payment collected.
- Put in requests for adjustments and handle write-offs.
Intake Specialist
Precision Healthcare Infusion
08.2015 - 03.2016
- Enter demographic and clinical information into the system upon receipt of referral.
- Created patient charts and initiating admission paperwork.
- Evaluated referrals against branch service model parameters.
- Complied with reimbursement for services and products in compliance with company policy and goals, to include drug, supply, and equipment selection for utilization, and participate in the submission of clean claims through compliance to proper pharmacy billing procedures.
- Verified insurance eligibility and benefits accurately in a timely manner in accordance with company policies.
- Obtained initial authorizations following insurance company policy and maintain authorizations extension for all patients.
- Processed all required paperwork according to established guidelines. Ensured all documentation needed for billing and services is collected prior to soon after accepting referral.
- Answer telephone calls and emails in a professional and timely manner.
A/R Representative
Solutions Management Services
04.2014 - 08.2015
- Analyze, audit, and resolve claims outstanding, denied, or incorrectly paid. Review and respond to the payer.
- Review and prepare claims for electronic billing submission.
- Print and review HCFA 1500 as necessary for account resolution
- Knowledge of Urology Billing and Coding within the state of California
- Interpret EOBs and Payer forms for manual billing according to payer requirements.
- Ensure that all claims have been received and processed.
- Submit appeals and medical records if needed to ensure the claim is processed and paid according to contract provisions.
- Recognize trends quickly to resolve issues within the EDI system.
- Follow up on all correspondence received to resolve the issue.
- Read Medical Records to ensure that the proper Modifiers have been added to the CPT codes for claim submission.
- Verify insurance coverage for patients to ensure proper reimbursement will be received.
- Trained new employees for new billing systems and company protocols.
Patient Account Representative
Xtend Healthcare
10.2013 - 04.2014
- Responsible for reviewing and follow-up to outstanding accounts and adhering to productivity guidelines as established by the department supervisor.
- Contact patients and insurance companies for collection of outstanding collection accounts
- Resolve outstanding accounts, following policy/procedure in resolving accounts write off, placement with collection agency, and appeals with insurance companies.
- Utilize and review reports to identify reimbursement problems with insurance companies.
- Composed letters to insurance companies and patients to resolve reimbursement problems.
- Telephone insurance companies to resolve contracts issues regarding rates of payment.
- Update patient’s files and insurance verifications
- Research and analyze accounts to determine whether a refund is due to commercial and governmental insurance provider.
Billing and Coding Specialist
TN Health Management
05.2013 - 10.2013
- Reviewed and verified assigned codes and sequences diagnosis and procedures according to regulations.
- Following up on outstanding claims with Medicaid providers for payment
- Identified billing issues from denials.
- Monitored insurance claims and contacted insurance companies to resolve unpaid claims.
- Performed complete account follow-up and resolution of patient accounts.
Billing and Outbound Verifications Specialist
Windsor Health
03.2011 - 05.2013
- Processed member’s payments using premium billing systems for check, debit, and credit card payments.
- Assisted members with billing issues to resolve any conflict and maintain accounting records.
- Requested refunds and submitted premium payment changes on behalf of members.
- Executed collection calls to obtain any premiums owed that are past due.
- Assisted with Medicare complaints regarding premium billing complaints.
- Followed Medicare guidelines.
- Called members to explain the plan’s benefits, explain the company’s protocol and verified if the plan the member enrolled in the correct plan.
CBCS
Comprehensive Health Services
10.2010 - 03.2011
- Assigned codes on all procedures, professional, and supplies with the most accurate and descriptive ICD-9-CM, CPT, and HCPCS codes for all patients’ encounters for reimbursement.
- Billed insurance claims electronically or manually using HCFA 1500 or UB04 forms.
- Verified insurance eligibility and follow up on all insurance denials.
- Collected patient payments and maintained billing records.
- Submitted reimbursement claim to insurance companies and government entities.
Education
Academy of Allied Health Careers
01.2011
Skills
- CPT CODING, HCPCS, ICD-10
- INTERPRETING EOBs
- BASIC OFFICE PROTOCOL
- INSURANCE FORM PREPARATION (CMS 1500 AND UB04)
- ANATOMY, PHYSIOLOGY, AND TERMINOLOGY
- EXPERIENCE WITH BILLING SOFTWARE: EPIC, MEDISOFT, CERNER, MEDIEVOLVE, EDI, ZIRMED, CPR, TRIZETTO, AND CPU
- MEDICAID, MEDICARE, and THIRD-PARTY INSURANCE BILLING
Timeline
Claims Liaison II
Centene Corp
05.2023 - 04.2025
Reconciliation Lead
Centene Corp
09.2021 - 05.2023
Claims Auditor Lead
Wellpath
09.2018 - 09.2021
Claims Research Specialist
Wellpath
07.2017 - 07.2018
Insurance Follow-Up Billing Specialist
Medical Billing Management
03.2016 - 04.2017
Intake Specialist
Precision Healthcare Infusion
08.2015 - 03.2016
A/R Representative
Solutions Management Services
04.2014 - 08.2015
Patient Account Representative
Xtend Healthcare
10.2013 - 04.2014
Billing and Coding Specialist
TN Health Management
05.2013 - 10.2013
Billing and Outbound Verifications Specialist
Windsor Health
03.2011 - 05.2013
CBCS
Comprehensive Health Services
10.2010 - 03.2011
Academy of Allied Health Careers
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