Denise Mike
Concord,NC
Summary
Denise has extensive 10 years' experience as a Remote Patient Care Advocate/Customer Service Representative Prior Authorization Coordinator, Scheduling Coordinator, Patient Account Rep III /Insurance Follow Up, Intake Rep and Reimbursement Specialist/ Site Coordinator /AR Benefits /Access Specialist. Experienced Customer Service Analyst with a strong background in providing exceptional customer support and building client relationships, follow up with patients on all billing questions/concerns, provide exceptional customer support in every phone call, experience in handling about 80 to 100 calls per day. Responsible for various reimbursement functions, included but not limited to accurate and timely claim submission, claim status, collection activity, appeals, payment posting, and/or refunds, until accounts receivable issues are properly resolved. Strong attention to detail and extensive knowledge of medical, dental, and legal terminology. Experienced at registering patients, scheduling appointments, obtaining prior authorizations, and recording and filing records. Experienced reimbursement /AR/access benefit verification specialist/patient care coordinator with over 7 years in medical billing, accounts receivable. Proficient computer skills: Microsoft Office Star, Nextgen Epic, VI-Wed (Encompass, Rush, Lynx, AS400, Word, Excel, Outlook, PowerPoint, Patient Plus, Microsoft Teams, Facet system, Du, lps, aus cavirs, and mers) medical billing/ insurance follow up AR/ account access specialist. 7
Overview
13
13
years of professional experience
Work History
Prior Authorization (PBM) Coordinator
Blue Cross Blues Shield
Remote
- 10.2023
- Answering telephones for patients and others regarding billing inquiries and resolving billing issues in a professional manner
- Gathering, reviewing, and verifying all pertinent information relating to participating healthcare providers
- Review and evaluate medical service requests, including procedures, tests, surgeries, and medications, to determine if prior authorization is required
- Verify patient insurance coverage, including benefits, eligibility, and limitations
- Obtain and document necessary insurance information to ensure accurate billing and reimbursement
- Prepare and submit prior authorization requests to insurance companies or third-party payers, adhering to their specific guidelines and requirements
- Maintain accurate and organized records of all authorization requests, follow-up activities, and outcomes
- Communicate with healthcare providers, insurance companies, and patients to obtain additional information, clarify requirements, and provide updates on the status of authorizations
- Stay up-to-date with insurance policies, guidelines, and industry regulations related to prior authorizations
- Ensure compliance with all legal and regulatory requirements, including patient privacy and confidentiality (HIPAA)
- Assist with appeals and denials related to prior authorizations, working closely with healthcare providers and insurance companies to gather necessary information and submit appeals within specified timelines
- Analyze denials and identify trends or areas for improvement to minimize future denials
- Perform periodic audits of prior authorization processes to identify any gaps or inefficiencies
- Collaborate with team members and stakeholders to implement process improvements and enhance overall efficiency and accuracy
- Collaborate effectively with healthcare providers, nurses, medical assistants, billing staff, and other members of the healthcare team to ensure a smooth and coordinated workflow
- Share knowledge, provide training, and offer guidance on prior authorization processes and best practices
- Responsible for the accurate resolution of Medical Record and Appeal Request/Responses, Member Submitted Claims, Credit Memos and Special Financial Request
- Serve as a liaison to ensure end to end resolution of inquiries received in accordance with the Inter-Plan Program (IPP) requirements
- Review, Research and Resolve request, responses, claims and inquiries by navigating multiple system applications/platforms and verifying data/information is accurate for proper resolution
- Partner with other departments to ensure education of company guidelines and Scorecard impacts/metrics
- Provide feedback of trends associated with downstream impacts and propose recommendations of improvements to increase overall partner plan, provider and member satisfaction
- Serve as a Subject matter expert on Inter-Plan business across all lines of business
- Identify gaps or inconsistencies in workflows, and/or processes; recommend updates, alternatives and/or solutions
- Serve as a point of contact representing department in meetings, handle special projects as necessary and provide training when needed
- Responsible for user acceptance testing: verification of results, escalation and reporting of findings and approval of final results and resolve.
HBVP Scheduling Coordinator
Mecklenburg County Public Health Department
Remote
10.2021 - 12.2021
- Answering telephones for patients and others regarding billing inquiries and resolving billing issues in a professional manner
- Contacted all new submitted Clients for the homebound vaccine, in an initial call and or registration
- Confirmed eligibility scheduling and appointments, for nurse to go the home and educate and administer Covid vaccine of the patient choice
- Verified client information and making sure there is not any compromises health issues, no positive covid testing in the past 14 days
- Utilize queue data to provide analytical support and recommendations for staffing resources to meet objectives
- Update schedules consistently and promptly to reflect real time and future changes (including time off, overtime, shift schedule variations, additions, modifications etc
- Created and print daily zip code base routes sheets for the HBVP teams, prioritize in the correct address order
- Restocked & prepared HB & D2D bags with all the correct needle size for each client on the list, with all medical needed necessities and emergency bags, clear and update nurses white board daily with number of and kind of vaccines needed for the next day route
- Restocked & cleaned homebound supply room, updated and print needed documents, forms, flyers make sure spreadsheet from excel are correct and printed according.
Reimbursement Specialist/ Site Coordinator /AR Benefits /Access Specialist
AmerisourceBergen/Lash Group
Remote
11.2016 - 03.2020
- Answering telephones for patients and others regarding billing inquiries and resolving billing issues in a professional manner
- Reviewed case and insurance coverage information to customize the contents of the call to the insurance company on behalf of the patients, followed HIPAA Guidelines
- Responsible for answering in-bound calls and assisted customers with dedicated client related services
- Contacted insurance companies to perform appropriate benefit investigation(s) and coverage eligibility for client product only
- Verified co-pays, insurance prior authorizations and up-dating records for Infusion dates and clearance
- If applicable, assisted with the completion of the prior authorizations with attention to detail and accuracy with provided information
- Assisted patients with the enrollment process for manufacturer and non-profit organization copy assistance programs
- Provided customers with courteous, friendly, fast and efficient service
- Worked efficiently both individually and within a team to accomplish required tasks
- Maintained and improve quality results by adhering to standards and guidelines and recommending improved procedures
- Completed prior authorizations with attention to detail and accuracy, to then have the prepared prior authorization reviewed by a clinical pharmacist
- Obtained client information by answering telephone calls; interviewing clients; verified information
- Followed up with insurance companies to ensure claims submitted and paid
- Resubmitted denials, appealed claims, and no response
- Read and understood, EOB SOP/VOB made sure they are corrected submitted
- Selected the appropriate ICD-10/ICD-9 insurance code based on the insurance provided by the client in the patients scanned requisition records
- Reviewed and corrected claims and returns, reconsideration
- Entered all insurance coverage information as noted in the patients scanned requisition record
- Screened and directed to client missing patient and demographic data that is critical to a claim
- Up-date with all carries the process as needed
- Initiated contact with the client customer service division or the ordering physician's office when key data elements were missing from the patients scanned requisition record
- Met benefit investigation process standards by completing the work list tasks in a timely manner and/or reported to management when assistance is needed
- Participated in team meetings by sharing the details of case work
- Updated and placed orders for shipment time and date of cold packed medications
- Responsible for various reimbursement functions, included but not limited to accurate and timely claim submission, claim status, collection activity, appeals, payment posting, and/or refunds, until accounts receivable issues are properly resolved
- This included demographic, authorization/referrals, National Provider Identification (NPI) number, and Tax Id numbers
- Physicians Coordinated with inter-departmental associates to obtain appropriate medical records as they relate to the reimbursement process
- Worked on problems of moderate scope where analysis of data requires a review of a variety of factors
- Communicated effectively to payers and/or claims clearing house to ensure accurate and timely electronically filed claims
- Effectively utilized various means for collections, including but not limited to phone, fax, mail, and online methods
- Completed and submitted all necessary insurance forms and electronic claims to process the claims in a timely manner as required by all third-party payers
- Set appointments scheduling medication delivery excellent people skills and dedicated work ethic
- Strong attention to detail and extensive knowledge of medical, dental, and legal terminology
- Experienced at registering patients, scheduling appointments, obtaining prior authorizations, and recording and filing records.
Reimbursement / Billing & AR- Benefit Specialist
Caring People Home HealthCare
Remote, Charlotte, NC
11.2014 - 08.2016
- Answering telephones for patients and others regarding billing inquiries and resolving billing issues in a professional manner
- Ensured all physicians diagnosis is the correct level of services for the patient care
- Made corrections and updated on various claims
- Manual cleaned up on all back end of the remits
- Followed up on all payer for HIPPA Guidelines
- Insured all CNA, nurse aids are clocked in on time tablet
- Did intakes for all case and patient care plans
- Home placement for caregivers, did end shift follow up
- Insured timesheets are entered on time and accurate
- Answered 45-60 calls daily/update data enter additional notes on client chart
- Insured All claims are processed correctly and timely for payments
- Followed up on all denied claims/ resubmit corrected claims
- Provided exceptional customer service to internal and external customers.
Patient Account Rep III /Insurance Follow Up Remote Specialist
Novant Health Presbyterian
Charlotte, NC
10.2013 - 11.2014
- Answering telephones for patients and others regarding billing inquiries and resolving billing issues in a professional manner
- Monitored patients' accounts and followed up with the insurance payer
- Collected payments for medical services
- Followed up on unpaid claims ensured that they were entered and submitted within 48 hours of receipt
- Post payments to patient accounts, updated and processed the patient statements
- Answered and resolved patients billing inquiries and make sure they understand the bill and payments
- Post Payments, reconciled, researched, and resolved incorrect payments, EOB'S rejections and other outstanding issues with the accounts ensure accuracy, verified and corrected the insurance claims and ICD 9/10), CPT Codes
- Insured all physicians' diagnosis is the correct level of services and made all corrections on various accounts needed on the back end and do manual claim clean up before sending out
- Made sure all payers are clear and in compliance with the HIPAA guidelines.
Medical Biller/ Patient Care & Intake Rep
Family Choice HealthCare
10.2008 - 07.2013
- Billing for Family Medicine, Ophthalmology, Dermatology, and Mental Health specialties
- Ensured claims are entered and submitted with 48 hours of receipt
- Accurately applied payments to patient accounts
- Posted and reconcile insurance and patient payments
- Researched and resolved incorrect payments, EOB rejections, and other issues with outstanding accounts
- Researched/resolved incorrect payments, EOB rejections, and other issues with accounts
- Insured accuracy of claims, verified correct ICD-9(ICD-10) and CPT codes for a variety of specialties
- Set up new patient accounts
- Assigned ICD-10/9 to physician diagnosis and insured correct level of service and CPT codes
- Monthly processed patient statements
- Answered and resolved patient billing inquiries
- Insured office practices are following HIPAA regulations
- Maintained frequent phone contact with provider representatives, third party customer service representatives, pharmacy staff, and case managers
- Collected and reviewed all patient insurance benefit information, to the degree authorized by the SOP of the program
- Global understanding of commercial and government payers preferred
- Exercised judgment within defined standard operating procedures to determine appropriate action.
Loan Processor/ Document Review Specialist/ Member Service Rep
NACA
06.2009 - 08.2012
- Advised NACA members of their individual options
- Primary Role: Provide Financial Assistant
- Loan Document follow up
- Loan Origination/Process
- Counseling/Education regarding pre-purchase
- Counseling to individuals and families and provide an Action Plan with options for the goal new home purchase and maintenance
- Available anytime for the interview anytime any day given 24 hours' prior notice.
Education
Skills
- Excellent with people skills and dedicated work ethic
- Enthusiastic Prior Authorization Specialist
- Customer Service outbound & inbound / 80calls daily
- Multi-line switchboard operation
- Strong interpersonal skills and communication skills
- Independent problem solver, good decision maker, and robust analytical skills
- Effective written and verbal communication
- Familiarity with verification of insurance benefits
- Work efficiently both individually and within a team to accomplish required tasks
- Strong attention to detail, flexibility, and the ability to adapt to changing work situations
- Versatility, initiative, applications support, administrative operations 8820
- Proficient computer skills: Microsoft Office Star, Nextgen Epic, VI-Wed (Encompass, Rush, Lynx, AS400, Word, Excel, Outlook, PowerPoint, Du, lps, aus cavirs, mers) medical billing/ insurance follow up AR/ account access remote specialist
Timeline
HBVP Scheduling Coordinator
Mecklenburg County Public Health Department
10.2021 - 12.2021
Reimbursement Specialist/ Site Coordinator /AR Benefits /Access Specialist
AmerisourceBergen/Lash Group
11.2016 - 03.2020
Reimbursement / Billing & AR- Benefit Specialist
Caring People Home HealthCare
11.2014 - 08.2016
Patient Account Rep III /Insurance Follow Up Remote Specialist
Novant Health Presbyterian
10.2013 - 11.2014
Loan Processor/ Document Review Specialist/ Member Service Rep
NACA
06.2009 - 08.2012
Medical Biller/ Patient Care & Intake Rep
Family Choice HealthCare
10.2008 - 07.2013
Prior Authorization (PBM) Coordinator
Blue Cross Blues Shield
- 10.2023
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