Carlin Franklin

• Manage the full billing cycle, including claim submission, payment processing, settlement, and follow-up for Medicaid and managed care insurance claims.
• Conduct thorough root cause analysis on unpaid and underpaid claims, identifying trends and resolving issues to ensure timely and accurate billing.
• Research and appeal claim rejections, underpayments, and denials using payer portals, re-billing, correcting coding, and communicating directly with payers and clinics.
• Address issues related to coordination of benefits (COB), demographic discrepancies, and Medicaid/Medicare eligibility to resolve billing discrepancies.
• Ensure compliance with Medicaid provider manuals and bulletins, correcting billing issues and updating claims accordingly.

• Processed claims in full compliance with CMS and DHS regulations, ensuring all Medicaid claims were submitted accurately and on time.
• Addressed claims-related inquiries, including subrogation and adjustment requests, communicating promptly and effectively with clients and internal teams.
• Exceeded production and quality standards, consistently achieving high claim resolution rates and minimizing claim denials.
• Assisted in root cause analysis to identify billing inefficiencies, providing solutions for quicker claims processing.

• Submitted accurate electronic claims via Epic for Medicaid and managed care plans, ensuring correct coding and reimbursement rates.
• Investigated unpaid or denied insurance claims, utilizing FinThrive to identify errors and take corrective actions, including rebilling and working with payers.
• Communicated effectively with third-party payers to resolve claims issues and discrepancies, maintaining a strong understanding of payer requirements.
• Ensured compliance with all billing policies and procedures to improve claims resolution time and reduce outstanding balances.

• Managed outpatient prior authorizations, providing support to providers and members to streamline processes.
• Coordinated with providers and patients to resolve prior authorization issues, ensuring coverage for services.
• Ensured timely communication and resolution for any Medicaid/Medicare eligibility issues, improving patient experience and reimbursement rates.

• Oversaw Medicaid eligibility determination and managed a team to ensure compliance with Medicaid regulations for a multi-facility operation.
• Resolved issues related to coordination of benefits, ensuring accurate billing and claims submission in accordance with Medicaid eligibility rules.
• Reconciled payment discrepancies, including identification and resolution of aged approvals and month-end reports.
• Supervised a team that handled high volumes of claims, identifying and implementing process improvements to reduce errors and improve collection rates.

• Managed appeals for No Fault, Liability, and Worker’s Compensation cases, ensuring prompt recovery of mistaken payments.
• Coordinated with insurance companies and attorneys to facilitate Medicare recovery, ensuring compliance with Medicare regulations.
• Addressed patient benefit-related denials, utilizing phone verification of plan requirements and financial risk assessments to ensure proper reimbursement.