Eunice Cueto

• Responsible for cash recovery for Yukon hospital according to company, client, and federal guidelines.
• Resolve and coordination of Workers Compensation Claims, Case Management .
• Investigation and process of claims reports and medical records supporting documentation.
• Verify member eligibility and benefits, determine provider contracting status, review of documentation EOB Benefits, medical records, and insurance plan documentation
• Account Reconciliation, Payments and Adjustments.
• Understanding of claim needs and ability to accurately perform needed billing activities (Evaluation/Correction of billing edits, claim transmission, EOB coding review, rejections, and other claim functions)
• Advanced understanding of commercial and Medicaid payers. MCD Perdiem.
• Knowledge of Medicare guidelines and able to accurately perform corrections according to CMS guidelines
• Excels in productivity standards as outlined by business line with minimum of 100% work quality scoring and accuracy on all accounts worked.

• RCM Account Receivable II, Review, research, and resolve complex claims processing issues, including Service
• Requests, Provider Disputes, Member billing issues in timely filing manner
• Coordinated Workers Compensation Claims Case Management with physicians and other health care professionals
• Investigated and processed claims reports and medical records supporting documentation
• Pain Management Auto/Liability Cases processing
• Make outbound calls/emails to resolve outstanding balances
• Prepare and maintain records of accounts receivables, including receipts
• Manage customer accounts, such as updating contacts, processing payments
• Appeals process first level and 2nd level to Medicare and Commercial Insurance Carriers
• Pain Management Billing and Collections
• Processing of over 30 cases daily while maintaining and exceeding production quota monthly over 100%.

• Review, research, and resolve complex claims processing issues, including Service
• Requests, Provider Disputes, member billing issues in timely manner
• Respond to complaints, grievances and appeals in consistent fashion, created effective solutions
• Adhering to all regulatory, accreditation and internal processing timelines and guidelines
• Processed Appeals with high level of efficiency, coordinating required documentation well as issuing written decisions letters to appropriate parties
• Pre-Authorizations Request/Approvals from hospitals, providers, customers and vendors via fax, phone, and portal according to time frames expedited or standard
• Achieved and consistently exceeded revenue quota through product and service production during routine calls
• Cultivated customer loyalty, promoted repeat customers, and improved sales
• Answered in-person email and telephone inquiries from customers
• Set up account files and educated members on details and use.

• Senior Billing and Recovery Case Specialist for CMS(Medicare)/Legal Audit Government
• Coordinated Workers Compensation Claims Case Management with physicians and other health care professionals
• Investigated and processed claims report and supporting documentation
• Processed Appeals with high level of efficiency, coordinating required documentation and preparing well as issuing written decisions letters to appropriate parties
• Review, research, and resolve complex claims processing issues, including Service Requests, Provider Disputes, member billing issues, adjustment projects and non- complex grievance and appeals, according to legal using established criteria of Medicare and independent insurance guidelines and policies
• Audit designated percentage of all daily processing production for assigned staff members (including errors from claims pricing, adjudication, adjustments, member bill issues, and mail)
• Provide feedback to appropriate. Claims Processing Supervisor or Claims Production Manager for processing staff to correct and/or adjust errors
• Conduct practitioner/provider group credentialing audits for initial, annual, and interim assessments in accordance commercial insurance and CMS regulatory requirements
• Verify member eligibility and benefits, determine provider contracting status, review of documentation EOB Benefits, medical records, and insurance plan documentation
• Posted electronic payment remittance (EPR), electronic funds transfer (EFT), resolve difficult issues working independently to case, by generating system/written decision letters according to case resolution
• Processing of over 30 cases daily while maintaining and exceeding production quota monthly over 100%
• Responded to customers request for products, services, and company information.
• Achieved performance goals on consistent basis.
• Collected on delinquent accounts to reduce overdue balances. Maintained consistently high success rate of collecting on overdue accounts.
• Regularly monitored accounts to identify overdue balances and potential areas of risk.

Verified insurance coverage by telephone and online to guarantee proper reimbursement of benefits and estimate patients' financial responsibilities

• Performed needs analysis to obtain information required to make appropriate health insurance product recommendations
• Scanned, received, and sent faxes to appropriate departments, including insurance claims, co-pay assistance information and patient documentation
• Achieved and consistently exceeded revenue quota through product and service production during routine calls
• Resolved grievances and created effective solutions
• Cultivated customer loyalty, promoted repeat customers, and improved sales
• Reviewed stop-loss reporting to customer accounts and complied with policies and procedures for release of information.
• Production Quota Products
• Checks, Demands, Defenses, Payments
• Denial’s investigation, Authorizations
• Exceeded annual revenue goals by 100% through improving client relationships and education

• Independently managed Billing (DME & Per Diem) paper CMS1500 and electronic primary, secondary and tertiary claims submissions
• Obtained pre-certifications, authorizations and referral process from health plans, hospitals, providers, customers and vendors via fax, phone, and portals for specialty care or treatments, and additional clinical testing
• Wrote letters of medical necessity, followed up on cases in medical review and handled denials/appeals from independent insurance co and Medicare
• Submits completed prior authorization forms to appropriate Utilization Management department
• Negotiate and enforce collections to recover funds on delinquent accounts. Settle years of open balances in patients accounts with successful collections of open balances
• Payment posting ensuring patients accounts are complete and ready for billing charge entry.
• Assists patients in scheduling of appointments with specialist or facility to which patient has been referred and scheduling transportation, if necessary
• Prepared code review for DME bill collection
• Created audit reports for cost control and better business processes
• Achieved revenue goals by managing collections and accounts receivables, referral process and insurance billing
• Filed and tracked insurance claims and communicated claims status to patients.

• Managed multiple accounts in monthly collections, which two of them were Ophthalmology and Gastrointestinal Surgical Centers.
• Slashed payroll/benefits administration in collection amount for each account of $100,000.00 monthly, while ensuring continuation and enhancement of services
• Monitor fee schedules and insurance payments to ensure fully allowed reimbursement
• Conduct weekly meetings with RCM team to provide guidance and feedback regarding claims processing
• Obtained pre-certifications, authorizations and referral process from health plans, hospitals, providers, customers and vendors via fax, phone, and portals for specialty care or treatments, and additional clinical testing
• Wrote letters of medical necessity, followed up on cases in medical review and handled denials/appeals from independent insurance co and Medicare
• Submits completed prior authorization forms to appropriate Utilization Management department
• Review, research, and resolve complex claims processing issues, including Service Requests, Provider Disputes, member billing issues, adjustment projects and non- complex grievance and appeals, according to legal using established criteria of Medicare and independent insurance guidelines and policies
• Audit designated percentage of all daily processing production for assigned staff members (including errors from claims pricing, adjudication, adjustments, member bill issues, and mail)
• Routine meetings by building solid relationships with business partners and specialist by fostering teamwork and collaboration regarding Financial, Collections and Health. Products.