Dekela S. James
Chickasaw,AL
Summary
To contribute to the success of your organization through the use of my skills, knowledge and experience in a professional manner QUALIFICATIONS: Dedication and drive as a hard-working team member Ability to manage multiple tasks in a fast-paced environment Exceptional versatility and adaptability; self-starter
Overview
25
25
years of professional experience
Work History
Referral Specialist
Altapointe/Accordia Health, Behavorial Health
03.2022 - Current
- Track and enter all referral requests in EHR System on a daily basis
- Prioritize Urgent referrals and follow entire process through to confirmed scheduled appointment
- Communicate and coordinate Health Center referral requests with outside specialists
- Request authorizations from patient’s insurance companies required by specialists
- Request authorization extensions or adjustments as requested by specialists
- Re-refer/re-schedule patients if they do not make their original referred appointment
- Provide contact information to patients asking for specific details about their appointments
- Answer, respond and document phone calls, request and questions from patients in a timely manner
- Routinely make notification phone calls to patients throughout the referral process
- Document every step of the patients’ referral process in EHR system
- Closes the final loop in referral tracking and document patient completion in EHR
- Communicate information via computer, phone, fax, and in writing to appropriate resources
- Respond to In-house provider questions, requests and concerns regarding the status of patient referrals, care coordination or follow-up status
- Called insurance companies to get precertification and other benefits information on behalf of patients.
- Verified insurance benefits and eligibility for order specialty procedures before referring clients.
- Assisted clients in locating resources that accepted various insurances.
- Answered telephone calls to offer office information, answer questions, and direct calls to staff.
- Maintained accurate records on in-progress and completed referrals, ensuring full data integrity throughout process.
- Built professional relationships with service providers.
Sort Assoicate
AMAZON
03.2020 - 12.2020
- At sortation centers, associates sort customer orders by final destination and consolidate them onto trucks for faster delivery
- Finance and Accounting (AltaPointe Health
- Worked varied hours to meet seasonal and business needs.
- Greeted customers and offered assistance for increased customer satisfaction.
- Prioritized tasks to meet tight deadlines, pitching in to assist others with project duties.
- Managed customer relations through communication and helpful interactions.
- Developed and implemented strategies to increase customer satisfaction and engagement.
- Monitored customer service metrics and performance indicators to identify areas of opportunity.
- Stocked merchandise, clearly labeling items, and arranging according to size or color.
Insurance Clerk
AltaPointe Health Systems, Behavorial Health
09.2019 - 03.2020
- Processes insurance claims for all center facilities
- File claims in a timely manner
- Perform follow-up procedures to ensure claims are paid
- Perform follow-up procedures on rejections to research potential issues and solutions
- Create pharmacy accounts receivable spreadsheets
- Obtain signatures on insurance vouchers when applicable
- Prepare electronic files for claims submission
- Prepare and mail manual insurance claims
- Responsible for maintaining accounts receivable records
- Accurate and timely posting of payments to client’s ledger to reflect correct account balance through payments and adjustments
- Post required internal insurance receipt reports
- Key updated insurance information into accounts receivable system
- Responded to inquiries from callers seeking information.
- Checked documentation for accuracy and validity on updated systems.
Health Information Professional
Adult Outpatient Clinic, AltaPointe Health Systems
01.2019 - 09.2019
- Health Information Professional
- Receives and processes all requests for health records from file area after consumers’ discharges
- Reviews and analyzes medical records for accuracy, completion, and timeliness of documentation
- Completes and processes authorizations to release of information as requested
- Answers the telephone in a professional manner using 5 Star Customer Service standards
- Assembles record in chronological order during review, and prepares record for imaging
- Checks and documents all chart deficiencies for nurses, doctors, therapists and behavioral staff (inpatient), and completes Administrative Reviews (Outpatient)
- Correctly categorizes deficiencies based on color coding system in use
- Obtains all missing information and corrects all deficiencies in records within standard compliance timeframes
- Protects and maintains the confidentiality of all records and patient information
- Maintains the chart tracking (charge-out) system to track the location of each record; assists clinicians with pulling locating charts
- Sorts incoming charts and ensures they are routed to the proper location and clinician; ensures charts are filed back promptly by the end of each workday
- Orders, maintains, and distributes AltaPointe approved forms
- Assists in purging records for destruction on a regular basis
- Adheres to program specific procedures and protocols as outlined by the Assistant
- Coordinator of Health Information
- Developed, coordinated and organized digital and tradition medical information and adhere to programs policy to address needs of clients and families.
Manager
Mobile Infirmary Medical Center
01.2017 - 12.2017
- Supervises Patient Financial Insurance Services Department claims inventory/workflow through claim life cycle
- Assist the Supervisor of the department with a variety of day to day tasks
- Assist and Supervise Patient Financial Services Insurance Department with analyzing medical necessity requirements and benefits, and communicates with necessary parties to ensure required data is documented in order for claims to be submitted expediently
- Assist and Supervise Insurance Services Department with analyzing admission and/or insurance records to ensure accuracy, completion and compliance with established procedures, regulatory requirements and insurance contracts
- Assist Insurance Analysts with collecting information from providers and technician’s necessary to support the medical necessity of billed services on disputed claims
- Assist Insurance Analysts with performing daily review of specified reports and provides follow-up and documentation necessary to update insurance files
- Assist Insurance Analysts by contributing to customer service by answering calls courteously and expediently, providing information and resolving customer problems relating to insurance coverage
- Assist Insurance Analysts with providing assigned support with other activities to meet departmental standards for customer and patient satisfaction
- Managed and motivated employees to be productive and engaged in work.
- Accomplished multiple tasks within established timeframes.
- Onboarded new employees with training and new hire documentation.
- Monitored and analyzed business performance to identify areas of improvement and make necessary adjustments.
- Developed and implemented business strategies to achieve business goals and stay competitive.
- Planned and budgeted accurately to provide business with resources needed to operate smoothly.
- Established team priorities, maintained schedules and monitored performance.
- Evaluated employee performance and conveyed constructive feedback to improve skills.
- Assisted in organizing and overseeing assignments to drive operational excellence.
- Defined clear targets and objectives and communicated to other team members.
- Used industry expertise, customer service skills and analytical nature to resolve patients concerns and promote loyalty.
- Maximized performance by monitoring daily activities and mentoring team members.
Team Leader
Mobile Infirmary, Insurance Services
05.2016 - 01.2017
- Supervises and assists in the daily activities of the area to provide timely and accurate billing and settlement of benefits due from third party payors, according to established HIS policies and procedures
- Work closely with the Manager and Director over the position’s assigned unit, responsible for various shifts
- Orients, trains, schedules and evaluates employees to provide qualified departmental staff
- Performs and integrates tasks designed to achieve timely and accurate settlement of accounts from third party payors
- Assigns and schedules work, including setting targets and deadlines
- Review and approve ETO, Time and Attendance
- Perform coaching and feedback and corrective action and performance evaluations
- Monitored team performance and provided constructive feedback to increase productivity and maintain quality standards.
- Supervised team members to confirm compliance with set procedures and quality requirements.
- Worked with team to identify areas of improvement and devised solutions based on findings.
- Established open and professional relationships with team members to achieve quick resolutions for various issues.
- Monitored time and attendance, enforcing compliance with company procedures relating to absenteeism.
- Communicated KPIs outlined in annual plan to inform employees of expectations and deliverables.
- Conducted regular reviews of operations and identified areas for improvement.
- Developed effective improvement plans in alignment with goals and specifications.
- Assisted in recruitment of new team members, hiring highest qualified to build team of top performers.
- Managed leave requests and absences and arranged covers to facilitate smooth flow of operations.
Insurance Analyst
Mobile Infirmary Medical Center
07.2014 - 05.2016
- Analyzes medical necessity requirements and benefits, and communicates with necessary parties to ensure required data is documented in order for claims to be submitted expediently
- Analyzes admission and/or insurance records to ensure accuracy, completion and compliance with established procedures, regulatory requirements and insurance contracts
- May collect information from providers and technicians necessary to support the medical necessity of billed services on disputed claims
- Performs daily review of specified reports and provides follow-up and documentation necessary to update insurance files
- Contributes to customer service by answering calls courteously and expediently, providing information and solving customer problems relating to insurance coverage
- Provides assigned support with other activities to meet departmental standards for customer and patient satisfaction.
- Maintained strict confidentiality with all personal data as per company guidelines.
- Viewed reports regularly to make sure processing was conducted efficiently.
- Generated, posted and attached information to claim files.
- Checked documentation for accuracy and validity on updated systems.
- Carried out administrative tasks by communicating with clients, distributing mail, and scanning documents.
- Processed and recorded new policies and claims.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
Insurance Verification, Supervisor
Premier Medical Mobile
09.2008 - 06.2014
- Verify insurance eligibility and benefits and precertification requirements for insurance companies such as Blue Cross and Blue Shield of Alabama and out of state, Medicare, Viva, Cigna, Aetna, Healthsprings, Unitedhealtcare etc
- Verify that the CPT and ICD-9 codes are billable and payable by the appropriate insurance company and the requirements of the patient’s health insurance policy prior to surgery, allergy testing and treatments and/ or any diagnostic testing being performed
- Verify services performed with the patient’s insurance company if precertification, notifications or authorizations are required and if so start the initiation process with the insurance company
- Verify that a patient with a work related injury has been authorized by his/her employer for treatment, which is known as “Worker’s Compensation”
- Obtain the correct billing information and written authorization of approval prior to treatment by the doctor from a Worker’s Compensation case worker
- Submit appeal letters with supporting clinical reports to the requesting insurance company
- Complied with HIPAA guidelines and regulations for confidential patient data.
- Assisted patients with understanding personalized insurance coverage and benefits.
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
Insurance Claims Clerk
Premier Medical
05.2002 - 09.2008
- File all paper and electronic claims to the appropriate insurance company in a timely manner via the computer system
- Research all accounts on the Blue Cross and Blue Shield pending report that have had no activity on the account within the last thirty days
- Check info solution program for claim status, eligibilities, and referrals for Blue
- Cross Blue Shield via the computer system
- Verify claims rejections from the insurance companies are correct
- Call the appropriate insurance company to verify claim status for payment
- Answer incoming phone calls from patients and insurance companies concerning accounts and payments
EYE & ENT Cashier
Premier Medical Mobile
09.2000 - 05.2002
- Collect co-pays, past due balances and prepays for upcoming surgeries or testing
- Post all charges, payments and adjustments listed on the fee ticket into the computer system
- Balance all payments received and prepare for deposit, and balancing the credit card machine against the credit card receipts
- Process returned mail and make address correction in the computer system
EYE & ENT Receptionist/ENT Receptionist, Ass. Supervisor
Premier Medical Mobile
01.1998 - 09.2000
- Check in patients for the appropriate doctor
- Enter new patients demographics into the computer as well as updating established patients demographics
- Make sure all patients that have an HMO policy have the proper referral
- Distribute faxes to the appropriate person
- Assist in supervising a nine staffed department
Education
Bachelor's - Business Administration
Faulkner University
Associate's - Business Administration
Southeast College of Technology
2000
Diploma - undefined
John S. Shaw High School
1998
Skills
- COMPUTER/CLERICAL SKILLS:
- Microsoft Office Works
- Internet
- Excel
- Ten-Key Calculator
- Fax/Copier Machine
- Credit Card Machine
- HIPAA Regulations
- Database Management
Timeline
Referral Specialist
Altapointe/Accordia Health, Behavorial Health
03.2022 - Current
Sort Assoicate
AMAZON
03.2020 - 12.2020
Insurance Clerk
AltaPointe Health Systems, Behavorial Health
09.2019 - 03.2020
Health Information Professional
Adult Outpatient Clinic, AltaPointe Health Systems
01.2019 - 09.2019
Manager
Mobile Infirmary Medical Center
01.2017 - 12.2017
Team Leader
Mobile Infirmary, Insurance Services
05.2016 - 01.2017
Insurance Analyst
Mobile Infirmary Medical Center
07.2014 - 05.2016
Insurance Verification, Supervisor
Premier Medical Mobile
09.2008 - 06.2014
Insurance Claims Clerk
Premier Medical
05.2002 - 09.2008
EYE & ENT Cashier
Premier Medical Mobile
09.2000 - 05.2002
EYE & ENT Receptionist/ENT Receptionist, Ass. Supervisor
Premier Medical Mobile
01.1998 - 09.2000
Bachelor's - Business Administration
Faulkner University
Associate's - Business Administration
Southeast College of Technology
Diploma - undefined
John S. Shaw High School
Similar Profiles
Amber ClausellAmber Clausell
Care Coordinator at Accordia HealthCare Coordinator at Accordia Health
NIKITA LEHMANNIKITA LEHMAN
COORDINATOR, ADULT OUTPATIENT SERVICES at ALTAPOINTE HEALTHCOORDINATOR, ADULT OUTPATIENT SERVICES at ALTAPOINTE HEALTH
Gina M. PressleyGina M. Pressley
Registered Nurse at AltaPointe Health SystemsRegistered Nurse at AltaPointe Health Systems