Carol Schmitz-Lessenger

Review and evaluate claims with a higher degree of complexity to determine appropriate benefits in accordance with policy provisions.

Audit high dollar release payments and provide ongoing development for the Team.

Train new claim examiners regarding system protocols and claims procedures.

Run historical reports to assist with claim investigations.

First line of support for team of Claim Examiners.

Ensure claims handling is conducted in compliance with applicable statues, regulations, and other legal requirements.

Review escalated calls for processing errors and ensuring corrections are completed.

Process recurring claims in a timely accurate manner.

Evaluates documentation received for proper management of claim.

Request needed documentation to ensure continued eligibility and maintenance of claims.

Follow up on all stale dated claims.

Track continued eligibility and remaining benefits of current claims.

Communicates policy information and claims decision information to Insured or authorized representatives.

Ensure handling of claims meets applicable statues and regulations.

• Manages all human resource functions including ad placement management of new hire requirements, preparation and update, at all time, of all personnel files, health files and other recordkeeping
• Create and audit HR files to ensure all documentation is complete and all expiration dates are current
• Processed all medical records request and employment verifications
• Establish office processes and procedures that focus making the agency efficient, cost-effective and patient care oriented
• Supports HIPAA compliance and keeps both patient and employee information confidential and secure
• Audit charts for billing to make sure all visit frequencies and orders match and have complete notes
• Oversees functions of order management and intake process
• Verify benefits, request and follow up on all insurance pre-authorizations
• Track and ensure additional authorization are obtained
• Make sure all incoming referrals are processed timely and have complete MD orders and clinical notes
• Provides effective supervision, delegation and guidance to assigned office staff
• Proficient in Outlook, Word, Excel and Wellsky/Kinnser software.

• Implemented/maintained Medical Office Management Systems electronic billing system
• Submission of claims and follow up of adjudicated claims
• Conducted insurance verification and prior authorization
• Obtained and checked Medicare census from nursing facilities for appropriate billing
• Scheduled/coordinated patient exams and provider services
• Engaged in oversight of all billing for, Medicare, Medicaid, private insurance and Skilled Nursing Facilities
• Resolution of billing issues through thorough process knowledge & in-depth research
• Ensured HIPAA compliance, proficient in ICD-10, CPT and HCPCS
• Maximized efficiency, reduced delinquency and increased accuracy of billing department
• Processed insurance payments, adjustments, transfer of responsibility and refunds
• Trained and supervised support staff
• Developed relationships with Ordering physicians, nursing facilities and home health agencies to assure excellent customer service for both patients and health care providers.

• Met demands of busy collections group by performing a high volume of daily calls
• Pursued unpaid hospital insurance claims, by making corrections to rejected claims and filing appeals.

• Scheduled patient appointments, verified insurance benefits and obtained prior authorization
• Billed insurance, followed up on denials and prepared patient statements
• Increased office organization by developing a more efficient filing system and customer database protocols.