Jennifer Hall
Bakersfield
Summary
Knowledgeable Utilization Review Specialist considered critical thinker and problem-solver due to dynamic patient care planning and understanding of InterQual and CALOCUS-CASII guidelines. Known for having great rapport with providers and insurance carriers. I am an independent worker who is results-driven, and I also work well in a team setting. I strive to learn new skills and take on new responsibilities in order to adapt to any changes to my position.
Overview
32
32
years of professional experience
Work History
Utilization Review Specialist
Embark Behavioral Health
11.2020 - Current
- Evaluated patient care plans for compliance with insurance guidelines and policies.
- Collaborated with healthcare providers to ensure appropriate utilization of resources.
- Analyzed clinical documentation to determine medical necessity and appropriateness of services.
- Trained and mentored junior staff on utilization review protocols and best practices.
- Managed a high volume of cases efficiently by prioritizing tasks and maintaining strict deadlines for completion of reviews.
- Contributed to organizational success by participating in quality improvement initiatives related to utilization management processes.
- Demonstrated strong analytical skills by interpreting complex medical records and synthesizing relevant information for utilization review purposes.
- Participated in ongoing professional development opportunities to stay current with trends and best practices in utilization review, bringing new insights back to the organization.
- Maintained strict confidentiality of patient information, adhering to HIPAA regulations and organizational policies regarding privacy and data security.
- Obtained authorizations from multiple insurance carriers for various levels of care.
Audit Associate
ACU-Serve Corporation
06.2019 - Current
- Conducted financial, compliance and operational audits.
- Identified audit risks, prepared budgets and coordinated with management and audit team in preparing related reports.
- Identified control gaps in processes, procedures and systems through in-depth research and assessment and suggested methods for improvement.
- Developed and implemented corrective actions to bring business areas in line with standards.
- Performed strategic planning, execution and finalization of audits.
- Completed audit papers by thoroughly documenting audit tests and findings.
- Prepared working papers, reports and supporting documentation for audit findings.
- Facilitated financial and operational audits, working with internal and external managers to communicate recommendations or issues surrounding audits.
Audit Services Representative
Pacific Pulmonary Services
01.2013 - 10.2018
- Collected and arranged information and entered details into computer database.
- Adhered to strict HIPAA guidelines at all times according to company policy.
- Processed monthly reports for department performance.
- Reviewed documentation for compliance with requirements and accuracy of information.
- Continually improved knowledge, skills and performance based on feedback and self-identified professional developmental needs.
- Developed and implemented improvements to billing system to maximize efficiency, reduce delinquency and increase accuracy.
- Coordinated with other internal departments and customers to keep operations running smoothly and solve both routine and complex problems.
- Initiated audit process to evaluate the thoroughness of documentation and maintenance of facility standards.
- Consistently complied with applicable laws and regulations and ensured facility adhered to Medicare and Medicaid regulations.
Medical Biller
Physician's Network Billing Service
10.2011 - 09.2012
- Collected payments that were made and applied them to patient accounts.
- Posted payments and collections on a regular basis.
- Reviewed outgoing bills for eligibility and accurateness.
- Transferred balances to correct payers.
- Prepared accounts that had past due balances of more than 120 days and transferred those cases to a collection agency.
- Completed client requests and advised supervisors of special needs.
Department Manager
Wal Mart Stores Inc
01.2010 - 10.2011
- Adhered to all safety procedures and company standards and policies.
- Implemented process improvement initiatives within the department.
- Mentored new sales associates to contribute to the store's positive culture.
- Welcomed customers into the store and helped them locate items.
- Answered customer telephone calls promptly and in an appropriate manner.
- Maintained knowledge of current sales and promotions, policies regarding payment and exchanges and security practices.
- Followed merchandising guidelines to present visually appealing displays.
- Fostered a positive work environment by consistently treating all employees and customers with respect and consideration.
- Stocked and replenished merchandise according to store merchandising layouts.
- Completed all cleaning, stocking and organizing tasks in assigned sales area.
Medical Billing Specialist
Option Care
08.2006 - 08.2007
- Ensured HIPAA compliance.
- Reviewed and solved account and billing discrepancies.
- Oversaw private and MCR billing and verified that proper procedures were followed.
- Assessed accounts for payment status and reached out to customers.
- Coordinated with intermediate parties to obtain payments and resolve issues.
- Collected and processed co-payments and out-of-pocket charges.
Pharmacy Billing Representative Lead
Pacific Pulmonary Services
04.2004 - 08.2006
- Reviewed and solved account and billing discrepancies.
- Assessed accounts for payment status and reached out to customers.
- Coordinated with intermediate parties to obtain payments and resolve issues.
- Performed quality assurance evaluations of processes and previous bills.
- Self-directed with astute judgment skills. High level of personal accountability.
- Performed account reconciliations and resolved variances.
- Oversaw financial operations, producing invoices, processing payments and preparing deposits.
- Contributed substantially to successful department JCAHO accreditation.
- Continually improved knowledge, skills and performance based on feedback and self-identified professional developmental needs.
- Hired, trained and coached on average of 15 employees per year.
- Oversaw private and MCR billing, payroll, AP, and AR and verified that proper procedures were followed.
- Ensured HIPAA compliance.
Department Manager
Wal Mart Stores Inc
07.1993 - 04.2004
- Built a talented and valuable team of departmental employees through outstanding mentoring, coaching and teaching skills.
- Implemented process improvement initiatives within the department.
- Ensured that all employees within the Jewelry department presented a positive, exemplary image to customers.
- Established performance goals for employees and provided feedback on methods for reaching those milestones.
- Determined customer needs by asking relevant questions and listening actively to the responses.
- Contacted other store locations to determine merchandise availability.
- Completed all daily tasks and special assignments with an efficient and quality-driven approach.
- Strategically scheduled team members to maintain optimal staffing levels at all times.
- Stocked and replenished merchandise according to store merchandising layouts.
- Directed work of as many as 10 employees focused on Jewelry.
- Trained new sales associates.
- Communicated clear expectations and goals to each team member.
- Handled all customer relations issues in a gracious manner and in accordance with company policies.
- Followed merchandising guidelines to present visually appealing displays.
- Completed all point of sale opening and closing procedures, including counting the contents of the cash register.
- Supervised and directed all merchandise and shipment processing.
Education
California State University - Bakersfield
Bakersfield, CAAssociate of Arts - English
Porterville College
Porterville, CA01.1990
Skills
- Data entry experience
- Process improvement
- Payment collection
- Insurance claims
- Customer relations skills
- Regulatory compliance
- Collections understanding
- EMR / EHR
- Patient privacy and confidentiality
- Medical records management
- Staff management
- Account monitoring
- Medical billing and coding
- Staff education and training
- Problem-solving
- Communication
- Decision-making
- Time management
- Detail-oriented
- Staff training and development
- Merchandising
- Basic administrative knowledge
- Skilled problem solver
- Experience with Brightree
- Clinical assessment
- HIPAA compliance
- Healthcare regulations
- Medicare compliance
- InterQual guidelines
- Private insurance policies
- Insurance verification
- Documentation and reporting
- Interpersonal and written communication
- Teamwork
- Teamwork and collaboration
- Problem-solving abilities
- Compassionate and caring
- Multitasking Abilities
- Reliability
- Excellent communication
- Task prioritization
- Self motivation
Timeline
Utilization Review Specialist
Embark Behavioral Health
11.2020 - Current
Audit Associate
ACU-Serve Corporation
06.2019 - Current
Audit Services Representative
Pacific Pulmonary Services
01.2013 - 10.2018
Medical Biller
Physician's Network Billing Service
10.2011 - 09.2012
Department Manager
Wal Mart Stores Inc
01.2010 - 10.2011
Medical Billing Specialist
Option Care
08.2006 - 08.2007
Pharmacy Billing Representative Lead
Pacific Pulmonary Services
04.2004 - 08.2006
Department Manager
Wal Mart Stores Inc
07.1993 - 04.2004
Associate of Arts - English
Porterville College
California State University - Bakersfield
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