JANETTE GRACIA
Lombard,IL
Summary
Medical Billing and Claims Specialist skilled in healthcare revenue cycle management, medical claims processing, and accounts receivable. Proficient in securing prior authorizations, resolving claim challenges, and managing high-volume billing operations with a focus on compliance and accuracy. Bilingual in English and Spanish, with a strong understanding of Medicare, Medicaid, and commercial insurance.
Overview
10
10
years of professional experience
Work History
Claims Specialist
Medtec Healthcare and Private Duty Co.
Morton Grove, USA
11.2013 - 02.2019
- Obtained and maintained portal access for Managed Care Organizations to facilitate timely claim processing.
- Secured prior authorizations and verified payer requirements for services to ensure compliance and reduce claim denials.
- Submitted and followed up on appeals for unpaid and denied claims.
- Researched claim issues and payer requirements to support accurate and timely reimbursement.
- Managed billing for the Illinois Department on Aging and Managed Care Organizations for in-home services, adult day care, and non-emergency transportation.
- Oversaw accounts receivable processes for accurate financial tracking. for in-home and adult day care services.
- Prepared documentation and supporting records for Illinois Department on Aging and Illinicare audits, enhancing transparency and accountability.
- Prepared Court of Claims submissions for prior fiscal years.
- Maintained organized billing documentation and records for audit and compliance purposes.
Medical Claims Specialist
Prescient Practice Management
Oakbrook Terrace, USA
10.2008 - 03.2012
- Managed revenue cycle activities for multiple medical specialties, including cardiology, dermatology, endocrinology, family practice, gastroenterology, general surgery, gynecology, infectious disease, neurology, obstetrics and gynecology, ophthalmology, orthopedics, pediatrics, psychiatry, and urogynecology.
- Specialized in Medicare, Medicaid, Managed Care, Commercial Insurance, and Workers' Compensation claims.
- Reviewed operative notes, diagnosis assignments, and progress notes to determine appropriate CPT coding and billing.
- Researched payer policies, billing guidelines, claim requirements, and reimbursement issues to ensure compliance and optimize claim processing.
- Established and implemented accounts receivable methodologies, enhancing claim follow-up and expediting payment resolution.
- Investigated claim status with third-party payers and resolved billing discrepancies.
- Coordinated with physician offices regarding claim challenges, HMO requirements, and authorizations.
- Submitted compliant third-party payer claims while maintaining HIPAA standards.
- Communicated with attorneys regarding itemized billing and invoicing.
- Prepared and deposited third-party payer remittances.
- Compiled delinquent patient account reports for provider review and disposition.
- Managed pre-collection activities for accounts totaling $3.2 million, ensuring timely resolution and minimizing revenue loss.
- Created structured payment plans for patients to facilitate manageable financial obligations. with patients.
- Sent qualifying patient accounts to collection agencies for further action. to collection agencies.
- Conducted weekly staff meetings and provided team leadership and supervision.
Education
Medical Insurance Billing & Coding Diploma -
Everest College
Skokie, IL10-2008
General Education -
Carl Schurz High School
Chicago, IL01-1997
Skills
- Revenue Cycle Management
- Billing and claims
- Medicare & Medicaid Billing
- Managed Care & Commercial Insurance
- Workers' Compensation Claims
- Claims appeals management
- Prior Authorizations
- Patient Account Resolution
- Accounts receivable management
- Medical coding standards
- Coding and review
- HIPAA Compliance
- Payer/Portal Experience
Additional Qualifications
- Bilingual: English & Spanish
- Excellent written and verbal communication
- Highly organized and detail-oriented
- Strong analytical and problem-solving skills
- Able to prioritize multiple deadlines in fast-paced healthcare environments
- Experienced working independently and as part of a team
- Strong knowledge of payer requirements and medical billing processes
Timeline
Claims Specialist
Medtec Healthcare and Private Duty Co.
11.2013 - 02.2019
Medical Claims Specialist
Prescient Practice Management
10.2008 - 03.2012
Medical Insurance Billing & Coding Diploma -
Everest College
General Education -
Carl Schurz High School