Johana Rolon
Raleigh,NC
Summary
Seasoned professional with 20 years in healthcare revenue cycle management, seeking a Senior Fraud Investigations Analyst - Medicare/Medicare advantage Investigations. Proficient in claims processing, account reconciliation, and customer service, as demonstrated at Blue Cross Blue Shield and Carenet Healthcare Services. Skilled in patient financial services, adept at negotiating payment plans for Commercial, Medicare ,Medicaid Federal plans and managing account receivables, collections/ Fraud ensuring compliance and efficiency.
Overview
17
17
years of professional experience
Work History
Federal Employee Claims Benefits Specialist
Blue Cross Blue Shield of North Carolina
07.2022 - Current
- Facilitate accurate claims filing with medicare advantage and benefits inquiries by guiding providers and members through the necessary processes.
- Ensure seamless customer experiences by directing clients to appropriate departments for specialized assistance.
- Deliver informative and solution-oriented support regarding federal employee program plans and medicare plans to both providers and members.
- Providing understand to Medicare & federal plans in BCBS by guiding to get better understanding of cost shares and deducible.
- Running report for all plan included Medicare, medicaid and federal programs plans and sending outstanding statements out for payment.
Account Receivable Specialist
LEGACY HEALTH
08.2021 - 07.2022
- Managed the billing system by diligently reviewing and resubmitting claims, ensuring accuracy and compliance with financial standards.
- Conducted thorough account reconciliations and maintained comprehensive receivables documentation, contributing to the integrity of financial records.
- Resolved irregularities and responded to inquiries, supporting overall financial management through the production of monthly reports and analyses for Medicare , Medicaid, UHC , Aetna etc
Patient Care Coordinator Part Time Night
Carenet Healthcare Services
12.2020 - 07.2022
- Coordinated patient access to medical care by facilitating communication with on-call nurses and doctors for immediate assistance and support.
- Provided critical support to individuals in crisis by engaging with suicidal patients, ensuring they received timely intervention from healthcare professionals.
- Managed prescription refill requests efficiently, ensuring urgent medications were authorized by on-call doctors for patient health continuity.
Market Access and Reimbursement Specialist
Pear Therapeutics Inc
10.2020 - 08.2021
- Conducted comprehensive benefit investigations to ascertain patients' healthcare coverage, facilitating patient access by effectively assisting with precertification, prior authorization, and appeal processes.
- Managed claims for reimbursement for Medicare, Medicaid, united health care, Anthem, ensuring accurate accounts receivable, payment reconciliation, and adherence to collections procedures; maintained diligent follow-up on coverage decisions with insurance entities.
- Served as an advocate for patient access, leveraging expertise in payer policies and CRM tools to resolve inquiries and navigate complex insurance processes, while ensuring compliance with confidentiality laws and reporting requirements.
Patient Pay Collection Coordinator - Team Lead
Diplomat Infusion Specialty
07.2019 - 10.2020
- Enhanced patient financial outcomes by effectively managing collections on outstanding accounts, demonstrating empathy and respect for patient sensitivities.
- Facilitated the resolution of insurance claims through proficient use of electronic claims systems and online provider tools, ensuring accurate coverage and claim processing.
- Collaborated with the accounts receivable manager to generate accurate month-end reports, contributing to the financial health and operational efficiency of the team.
Medical Billing & Collection Specialist
Capital City Surgery Center
08.2018 - 07.2019
- Managed overdue accounts by issuing notices, recording payments, and maintaining detailed financial records, resulting in improved account status tracking and repayment plan establishment based on individual client capacity.
- Negotiated payment arrangements and credit terms, ensuring clear communication of default consequences and policies, and contributed to the creation of delinquency reports to aid management decision-making.
- Processed insurance claims and handled payer denials, effectively using medical billing software to streamline operations, and provided support by facilitating access to financial assistance programs for patients and their families.
Payment Poster & Medical Billing Coordinator (Contract Position Through Quality Staffing)
UNC Johnston Hospital
02.2018 - 07.2018
- Accurately generated and issued patient invoices, ensuring proper calculation of charges based on services documented in patient charts, and facilitated clarifications with physicians as needed.
- Addressed and resolved billing discrepancies by liaising with insurance companies and patients, providing explanations of insurance contracts, and negotiating settlements to uphold patient satisfaction and financial integrity.
- Enhanced billing department efficiency by diligently maintaining and updating patient and invoice records, analyzing billing data to identify trends, and contributing to departmental goals through proactive engagement in professional development opportunities.
Reimbursement Specialist
Amerit Consulting
07.2017 - 09.2017
- Conducted thorough research on payment discrepancies, denials, and account details to ensure accuracy, resulting in the timely preparation and submission of secondary or tertiary insurance claims and necessary appeals.
Patient Financial Services Representative
UNC Healthcare
03.2015 - 07.2017
- Analyzed account data to identify and rectify overpayments, contractual inconsistencies, and inaccuracies in financial status, ensuring compliance and financial integrity.
- Partnered with clients to assess outstanding accounts and strategize on subsequent collection activities, enhancing client relationships and revenue recovery.
- Liaised with Collection Agencies to negotiate account settlements based on client guidelines, and managed the posting of insurance adjustments and the redistribution of misapplied funds.
Patient Account Representative (Contract Position Through Accounting Principal)
Duke- PRMO
02.2014 - 03.2015
- Resolved delinquent accounts by identifying discrepancies, correcting errors, and securing missing information to expedite payments, successfully following up on outstanding claims with various insurance entities including commercial, Medicaid, and Medicare.
- Developed and monitored payment plans for overdue accounts, facilitating negotiations with debtors, and coordinating the transfer of unresolved cases to collection agencies as required. Managed data entry, prepared accurate calculations, and maintained financial records.
Case Manager
HMS Inc
11.2010 - 12.2013
- Managed a portfolio of Medicaid recipient claims, ensuring accuracy and punctuality in documentation and processing; addressed and resolved denied cases through thorough investigation and reclamation efforts.
- Facilitated effective communication among recipients, insurance adjusters, and legal representatives by maintaining exceptional customer service practices and providing translation services for Spanish-speaking clients.
- Contributed to team proficiency by developing and delivering comprehensive training to new employees on administrative procedures for Casualty and Estate recovery operations.
Medical Billing Specialist
Millennium Laboratory
06.2010 - 10.2010
- Accurately converted medical procedures into corresponding insurance codes, ensuring precision in claim submissions.
- Managed and reconciled rejected claims, updated patient medical records for outstanding balances, and executed follow-ups on delinquent third-party insurance claims, enhancing collection efforts.
Medical Billing Specialist (Contract Position Through Manpower)
Caduceus, Inc
07.2009 - 01.2010
- Managed account payments, ensuring accurate posting and reconciliation, and established tailored budget payment plans based on patients' financial assessments.
- Maintained HIPAA compliance while reviewing account statuses to initiate appropriate follow-up actions with insurers, resolving denials, and expediting outstanding third-party claims.
Rina Chawla Hand Therapist
Student Federal Work Study
04.2009 - 07.2009
- Maintained meticulous patient records and coordinated appointment scheduling, ensuring seamless daily operations within the therapy clinic.
- Efficiently managed insurance denials and facilitated the collection process, while accurately processing financial transactions including charges, payments, and adjustments.
Clerical Assistant, Guest Relations Department (Contracted Through Winston Staffing)
Lincoln Medical & Mental Health Center
11.2008 - 03.2009
- Compiled and prepared comprehensive monthly statistical reports by collecting and organizing departmental data, ensuring timely and accurate documentation for review.
- Developed databases, spreadsheets, and graphic presentations to support departmental activities, and assisted patients with inquiries and feedback collection integral to the monthly reporting process.
Education
Bachelor's - Science and Health Services Management
Berkeley College
New York, NY06.2012
Skills
- Five 9 Soft Phone
- Medicare advantage
- Medical Records
- Management
- SSI Software
- Data Entry
- Medical Office Experience
- Databases
- Medical Collection
- Medical Billing
- Customer Service
- Cerner
- Microsoft Outlook
- CPSI Software
- Sales
- Medical Scheduling
- Oracle
- Medical Terminology
- 10 Key Calculator
- Microsoft Excel
- Medical Coding
- Billing
- Data Mining
- Insurance Verification
- CPT Coding
- Icd-10
- Medical Invoicing
- Laboratory Experience
- Typing
- Records Management
- EMR Systems
- Infusion
- Salesforce
- Documentation Review
- Software Troubleshooting
- Guest Relations Experience
- Microsoft Word
- Time Management
- Epic
- Phone Etiquette
- Eaglesoft
- Icd-9
- Maestro
- Computer Literacy
- Microsoft Office
- Medical Receptionist
- Hipaa
- Leadership
Timeline
Federal Employee Claims Benefits Specialist
Blue Cross Blue Shield of North Carolina
07.2022 - Current
Account Receivable Specialist
LEGACY HEALTH
08.2021 - 07.2022
Patient Care Coordinator Part Time Night
Carenet Healthcare Services
12.2020 - 07.2022
Market Access and Reimbursement Specialist
Pear Therapeutics Inc
10.2020 - 08.2021
Patient Pay Collection Coordinator - Team Lead
Diplomat Infusion Specialty
07.2019 - 10.2020
Medical Billing & Collection Specialist
Capital City Surgery Center
08.2018 - 07.2019
Payment Poster & Medical Billing Coordinator (Contract Position Through Quality Staffing)
UNC Johnston Hospital
02.2018 - 07.2018
Reimbursement Specialist
Amerit Consulting
07.2017 - 09.2017
Patient Financial Services Representative
UNC Healthcare
03.2015 - 07.2017
Patient Account Representative (Contract Position Through Accounting Principal)
Duke- PRMO
02.2014 - 03.2015
Case Manager
HMS Inc
11.2010 - 12.2013
Medical Billing Specialist
Millennium Laboratory
06.2010 - 10.2010
Medical Billing Specialist (Contract Position Through Manpower)
Caduceus, Inc
07.2009 - 01.2010
Rina Chawla Hand Therapist
Student Federal Work Study
04.2009 - 07.2009
Clerical Assistant, Guest Relations Department (Contracted Through Winston Staffing)
Lincoln Medical & Mental Health Center
11.2008 - 03.2009
Bachelor's - Science and Health Services Management
Berkeley College
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