Keshia Frederique

• Educate employees, including case specialists and other QA Specialists, on healthcare related to Quality Standards, terminology, procedures, and related information
• Analyzes large sets of data and reporting relative trends to management, and handle complex questions, or quality related issues
• Initiate applicable action and documentation based upon quality audit reviews with respective team leads and managers within the organization
• Ensures the system updates are completed by caseworkers following quality audits that result in a necessary correction
• Provides training to other QA team members
• Responsible for maintaining impartiality and strict confidentiality on quality audit results
• Follows through to ensure auditing and reporting activities is on-time and accurate in accordance with policies and procedures
• Effectively communicate quality audit results to employees, and effectively escalate disagreement with audit findings through the appropriate procedures
• Arrives to work on-time, works assigned schedule, and maintains regular attendance
• Follows and complies with company and departmental policies, processes and procedures
• Responsible for utilizing resources to ensure compliance with client requirements, HIPAA, as well as applicable federal or state regulations
• Successfully completes, retains, applies and adheres to content in required training as assigned
• Consistently achieve or exceed established metrics and goals assigned
• Demonstrates Performant core values in performance of job duties and all interactions
• Ability to work independently to select random sampling to carry out assigned audits
• Work mandatory and Voluntary overtime weekly
• Work on holidays due to client requirements
• Work assigned casework to meet organizational needs and stay current on case knowledge
• Performs other duties as assigned.
• Managed budgets and resources, optimizing allocation for maximum impact on business objectives.
• Developed and executed strategic plans to achieve organizational goals and drive sustainable growth.
• Led cross-functional teams for successful completion of projects, resulting in increased productivity.

• Enhanced product quality by implementing comprehensive QA processes and procedures.
• Reduced defects in products by conducting thorough inspections and identifying areas for improvement.
• Streamlined testing processes by introducing automated tools, increasing efficiency and reducing errors.
• Improved customer satisfaction ratings through meticulous attention to detail and consistent quality control measures.
• Collaborated with cross-functional teams to identify root causes of product issues, leading to timely resolutions and continuous improvements.
• Trained team members on quality assurance principles, fostering a culture of accountability and high performance.

• Work off of an aging report, that consists of denied and rejected claims
• Check the eligibility of Medicaid, and Commercial insurance plans for the dates of services billed through Availity, the Medicaid portal, by calling the insurance carriers, and through online carrier portals
• Contacted the Insurance Carriers in order to obtain authorization for the entire stay of the Patient
• If claim denied for not medically necessary or no authorization
• Filed an appeal with the patient’s medical records, and write a short but, persuasive explanation as to why these claims should get paid
• Post checks, money orders, and EFT deposits paid to the facilities
• Contact Patients, and requested information that was needed to update their name, address, social security number, new insurance I.D numbers, and other personal information that is needed for the processing of their claims
• Process refunds; if an overpayment was made; or the insurance paid while the patient was not covered
• Verified benefits that are covered under the patients plan; and verify whether services require prior authorizations or referrals
• Contact insurance carriers requesting claim status, filed appeals, and if claim was denied incorrectly; request to have the claim sent back to be reprocessed
• Contacted Patients via mail and by phone requesting COB update, or any other active insurance policy that was not provided
• Correspond via email, and by phone with physicians; in regards to obtaining needed or missing signatures, licenses, and urgent documents that need to be authorized.

• Worked off an AR (aging report) to collect on Neonatal claims for Memorial Hospital.
• Billed Self-pay clients their outstanding balances, after insurance has paid.
• Updated clients phone numbers, addresses, email address, etc. in order to skip trace the most updated information for better chances of recovery.
• Billed claims through provider portals, printed/mailed medical records to Insurers to prove medical necessity.
• Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
• Updated W9's for providers, and group members to ensure providers credentials were correctly reflected in the system.

• Processed complex insurance billing claims though major insurances; for commercial payers, Medicaid, and Medicare.
• Identified and resolved billing discrepancies and correcting CPT and ICD codes to ensure maximum reimbursement
• Facilitated appeals by gathering the appropriate documentation required to prove medical necessity.
• Submitted electronic claims and followed up on unpaid account with major insurance carriers.
• Increased efficiency by streamlining data analysis processes and implementing automation tools.
• Developed new analytical models that improved forecasting accuracy and reduced risk exposure.

• Reduced errors in medical billing by meticulously reviewing patient records and ensuring accurate coding.
• Enhanced revenue collection through diligent follow-up on unpaid claims and denials with insurance companies.
• Monitored changes in payer requirements, adjusting billing practices accordingly to minimize disruptions in the revenue cycle.
• Efficiently processed refunds or adjustments for patients when necessary, ensuring accuracy and compliance with company policies.
• Provided exceptional customer service to both patients and insurance representatives, resolving inquiries quickly and professionally.
• Coordinated with other departments to address any discrepancies or concerns related to charge capture or data entry accuracy.

• Facilitated on-site activities, support groups and outings for clients.
• Kept facility clean, performed basic maintenance and restocked supplies to support
program needs.
• Built and maintained positive staff relationships to promote teamwork and better serve
clients.
• Prepared and submitted daily reports to management.
• Recognized individuals under influence of drugs or alcohol and typical behaviors
associated with each.
• Completed documentation for every incident and forwarded to correct personnel for
review.
• Searched resident belongings prior to and during stays.
• Escorted patients from unit to meals, activities and visitation areas to maintain standard
of safety and security.

• Enhanced patient care by conducting thorough utilization reviews and ensuring adherence to treatment plans.
• Reduced healthcare costs for the organization by identifying areas of improvement in clinical documentation and resource allocation.
• Maintained regulatory compliance by staying updated on industry standards and guidelines, implementing changes when necessary.
• Improved interdepartmental communication by collaborating with medical professionals, case managers, and social workers to develop comprehensive care plans.
• Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
• Communicated with healthcare team members to plan, implement and enhance treatment strategies.

• Escorted patients from unit to meals, activities and visitation areas to maintain standard
of safety and security.
• Identified behaviors that necessitated intervention and obtained assistance from qualified
personnel to complete intervention.
• Performed scheduled patient safety checks and documented results to establish patients'
well-being.
• Observed patient behaviors and mental status and notified RN of unusual or potentially
dangerous occurrences.
• Assisted with patient restraint and seclusion scenarios to create safe environment for
patient and medical personnel.
• Helped patients with meals, activities of daily living (ADLs) and facility transfers to
promote security and patient well-being.
• Attended therapeutic educational group meetings and supported patients with guidance
from RN medical professional.

• Worked referrals that were received from Doctors, NNP’s, and other help care professionals, requesting equipment for disabled and Medicare eligible patients.
• Worked off of an aging report for Medicare patients that were in need of Durable Medical equipment.
• Verified eligibility and benefits; before placing the order on behalf of the patient; to ensure company would be paid for services.
• Schedule the delivery and installations of the equipment
• Maintained constant communication with the patients in the event the patient passed away.
• Would schedule to have the equipment recovered (picked up).
• Made sure to have monthly or annual deductibles were paid; to ensure the continuing lease of the equipment.
• Constantly verified patient’s benefits.
• Received mailed in payments by check; and would post them to the patients account.
• Contacted insurance carriers to ensure requested changes or modification would continue to be covered.
• Or whether a substitute could be authorized.