Carolyn Cooper
STATE_US
Summary
Looking for a full-time 100% REMOTE position with remote experience. Diligent Medical Claims Analyst with strong foundation in analyzing and processing medical claims. Proven track record of identifying discrepancies and ensuring compliance with healthcare regulations. Demonstrated expertise in utilizing problem-solving skills and attention to detail to resolve complex claims issues effectively.
Overview
12
12
years of professional experience
Work History
Medical Claims Analyst
Luminare Healthcare
Remote
04.2023 - Current
- Analyze medical claims for accuracy and compliance with industry regulations.
- Collaborate with healthcare providers to clarify claim discrepancies.
- Research and resolved medical claims issues to support timely processing.
- Pay or deny medical claims based upon established claims processing criteria.
- Evaluate medical claims for accuracy and completeness and researched missing data.
- Process PT, OT, Massage Therapy, Behavioral; Speech and Chiropractic claims.
- Handle Correspondence from providers.
- Work multiple claims needing Authorizations.
- Request Aetna pricing when claim priced incorrectly.
- Work Family Files for Eligibility, Demographics, Claims History and Duplicates.
- Use SharePoint and the BRS system to assist with correct processing for the plan.
- Demonstrate high level of Evaluations.
- Managed any Internal Audits that I pended for investigation on a claim.
A/R RCM Billing Specialist
Mindpath Health/Community Psychiatry Associates
REMOTE
02.2021 - 02.2023
- Worked Telehealth claims for California Behavioral Health Providers.
- Managed all Mental Health claims in the NextGen system.
- Corrected Claims to resubmit claims electronically through NG Clearing House.
- Worked Primary and Secondary claims for full contracted rates.
- Worked Government plans for Medicare, Blue Cross and Tricare claims.
- Followed-up on underpaid claims that didn’t reimburse the allowable rate.
- Work all Back End claims for denial resolutions.
- Worked claims through Availity for Anthem BC and Anthem Medi-cal.
- Electronically or manually mail/fax Medical Records as needed.
- Experience with Overpayments and Recoupments.
- Worked adjustments for CO45 small balances.
- Worked Crossover claims from Medicare to the Secondary payers.
- Electronically Dispute UNDERPAYMENTS.
- Learned Trends that may be going on with Providers or the Insurance Payers that’s causing denials.
- Use the Lockbox for Insurance Correspondence when sent.
- Verifying COB issues.
- Task Coding department for any coding issues to rebill denied claims.
Hedis Abstractor
Optum/UHC
REMOTE
07.2019 - 02.2020
- Daily logged into ChartFinder to Abstract 5 Measures Pain, CBP, COAMR, FSA, COLO.
- Completed OR charts for the PAIN measure.
- Maintained Chart Finder and Business Hours weekly
- Extracted relevant data from clinical documents for efficient information retrieval and analysis.
- Conducted thorough medical record reviews to ensure accuracy and compliance with industry standards.
Member Services Agent
Broad-Path
REMOTE
11.2018 - 03.2019
- Assisted the client with their insurance plans (Ambetter) with the ACA in multiple states and focused on resolving issues for the members with their Billing and benefits so they may understand what coverage they qualified for and what amount was needed out of pocket for their deductibles or coinsurance.
- Assist members with payments online towards their monthly premium for their medical policy.
- Supported members with account management tasks, including updating personal information and troubleshooting login issues.
Billing Specialist
NEGC
Detroit, MI
10.2014 - 10.2016
- Generated all Commercial Billing monthly for Medicare, BCBS, Commercial and Medicaid Injections
- Completed all back-billing submissions to capture the previous months that needed to be finalized.
- Reconciled rejections and denials.
- Completed Commercial A/R postings in ECRIS.
- Updated new hires, assisted Doctors and Request documentation for Credentialing for Staff.
- Verified Eligibility for Commercial Insurance and submitted Authorization Request.
- Cleared Rejections and Errors in the Netwerks system to re-submit for payment.
- ATP: Completed Monthly Statement Reports on Excel Spreadsheets.
- ATP: Completed payment posting and documented cash, checks and money orders on Excel Spreadsheets.
- COFR: Macomb County and CMH Billing in FOCUS systems:
- Ran Service log reports from FOCUS and data entry the services on the claims to be adjudicated for payment.
- Reported any issues with authorizations and overlapping times with clinicians or providers as needed.
- Oakland Family Services and Easter Seals Billing in ODIN systems:
- Submitted all the OFS and ES billing for reimbursement.
Education
Associate of Science - Tax Preparer Training
Accounting Aid Society
12-2013
Medical Insurance Billing Program
Carnegie Institute
Troy, MI09-2012
Associate Degree - General Studies
Wayne County Community College
Detroit, MI06-1998
Skills
- Citrix, Family Files, BRS\LRS, SharePoint, D365, Web Dennis, HEDIS, WPS/MEDICARE (C-Snap), ECRIS, LARA for Credentialing,
- ICD-9, CPT-10, Medical Terminology
- Claims processing proficiency
- HIPAA compliance
- Healthcare regulations
- Claims review
- MS office
- Healthcare common procedures coding system (HCPCS)
- Report and records review
- Denied claims identification
Timeline
Medical Claims Analyst
Luminare Healthcare
04.2023 - Current
A/R RCM Billing Specialist
Mindpath Health/Community Psychiatry Associates
02.2021 - 02.2023
Hedis Abstractor
Optum/UHC
07.2019 - 02.2020
Member Services Agent
Broad-Path
11.2018 - 03.2019
Billing Specialist
NEGC
10.2014 - 10.2016
Medical Insurance Billing Program
Carnegie Institute
Associate Degree - General Studies
Wayne County Community College
Associate of Science - Tax Preparer Training
Accounting Aid Society