JOSHUA OCASIO

• Process incoming prior authorization calls from providers
Which entails verifying ICD10 and CPT codes and knowing
when to request specific modifiers (LT, RT, 50).
• Approve requests when codes meet criteria for
non-clinical administrative approval.
• Pend request and request clinical notes when procedures
require nurse clinical review.
• Developed and maintained medical records to ensure
that all information received was documented and filed
in an electronic database system for Nurse review.
• Verify Benefit plan specifics. Confirm referrals, when
required, by plan and out-of-network coverage
availability when utilizing a non-participating provider or
facility.
• Advising providers of denial decisions and informing the
office of available options preceding denials. (Peerto-peer option or appeals option, when qualifying).
• Informing providers of Medicare turnaround, time when
processing routine and expedited cases, to be within
compliance.

• Triage resulting in rework to appropriate staff
• Help guide members through their benefits plan, Aetna policy, procedures, and knowledge resources to comply with regulatory guidelines
• Investigated and resolved customer inquiries and complaints quickly.
• Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievances, and appeals (member/provider)
• Educate providers on our self-service options
• Assist providers with credentialing and re-credentialing issues
• Determine medical necessity and applicable coverage provisions and verify member plan eligibility for incoming correspondence and internal referrals
• Handle incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management
• Review member claim history to track benefit maximums and coinsurance/deductible
• Perform financial data maintenance as necessary
• Use helpful system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
• Answered telephone calls promptly to avoid on-hold wait times.
• Consulted with outside parties to resolve discrepancies and create expert solutions.

• Correctly coded and billed medical claims for Ambulance Services.

• Accurately selected proper descriptive code when more
than one anatomical location was indicated.
• Verified signatures and checked medical charts for
accuracy and completion.
• Applied charges and updated patient records by using
Zoll.
• Confirmed Medicare or Medicaid eligibility with online
tools.
• Utilized active listening, interpersonal and telephone
etiquette skills when communicating with others.

• Collaborate with Clinical trainers and management to administer training programs for new hires and transfers into non-clinical and clinical role(s)
• To ensure competence and proficiency in all computer software and clinical documentation platforms needed to perform their job role, essential duties, and responsibilities
• Follow contract-specific non-clinical and clinical staff training requirements on applicable standard operating procedures, job aids, data entry strategies, and policies
• Designed and maintained all internal process documents and training materials
• Collaborate with Contract Assistant Team Leads, OrthoCare Manager Team Leads, managers, and directors to identify and develop refresher/remediation training programs for existing staff
• Train new hires to view and pull language from member Certificate of Cover/Summary Plan Description to prepare request for medical necessity review
• Look up state and federal mandates and state requirements to ensure compliance with medical review
• Communicated changes to staff to ensure that supplemental training, process updates, and system changes stay compliant.

• Responsible for review and processing of new charges set up for both Professional and Hospital billing by utilizing software and analytical tools to monitor and maintain complete, accurate, compliant, and standardized CDM for Western Connecticut Health Network
• Ensure charge requests from Medical Group or Hospital Departments meet Medicare, Medicaid, and commercial billing regulations
• Provide support, education, and guidance to clinical departments and providers to ensure revenue integrity and appropriate charge capture.
• Maintained updated knowledge of coding requirements, through continuing education and certification renewal.
• Guarded against fraud and abuse by verifying coded data accurately reflected services provided.
• Resourcefully used various coding books, procedure manuals, and online encoders.
• Verified signatures and checked medical charts for accuracy and completion.
• Entered orders into EMR system efficiently and without errors.

• Conducted monthly audits to identify operational compliance within the department
• Created Audit case files and provided a summary of findings to be shared with Management and Operational Areas before submission to staff members.
• Participate in on-site / webinar audits, as needed
• Utilized monitoring tools to identify operational performance with compliance metrics.
• Outreach to Management if monitored items are at risk of being non-compliant
• Provide weekly/monthly/quarterly/annual reports summarizing results and corrective actions.
• Mentored and trained new employees as directed by Supervisor and director.

• Reconciled requests with member benefit information and applicable Oxford Corporate Policy. Also processed pre-certifications, which included verifying ICD-10 and CPT procedure codes.
• Verified Benefit plan specifics. Confirmed a referral is on file when required by the plan or out-of-network coverage was available when utilizing a nonparticipating provider or facility.
• Requested clinical notes from provider offices, when unable to administratively approve, within the time frame allotted by the state requirement, maintaining compliance.
• Developed and maintain medical records to assure that all information was received, recorded, and file adequately in an electronic database system for Nurse review.
• Preparing cases for Nurse review, which included citing State and Federal mandates and state requirements, along with pulling applicable benefit language from the Summary Plan Description or Certificate of Coverage.
• Administratively denying precertification request when the request is a benefit exclusion.
• Developed professional relationships with member physician offices and managed care payer personnel.

• Process accurate and timely medical charge entry for diagnoses, procedures, and physicians’ offices and hospital services
• Reviewed charges for accuracy, followed up on any preliminary charges, and promptly made corrections
• Resolved charge capture, medical necessity, claims denials, and bundling issues
• Established excellent service and working relationships with physicians, clinical and office staff, and WHA Central Business Office.
• Maintained knowledge of medical coding rules and regulations, including compliance and reimbursement.

• Responsible for accurate and efficient coding and abstracting of outpatient records using Haney’s, Paragon, Emergisoft, and HPF applications. Areas of expertise include Orthopedics, Labor and Delivery, Non-Stress tests, Laboratory, Sleep Study, Emergency Room, and Radiology Coding.
• Tactfully interacted with professionals, non-professionals, and physicians for questionable diagnoses and documentation issues to facilitate timely coding and billing of accounts while meeting medical necessity
• Worked closely with Coding Supervisor to improve clinical documentation and medical necessity issues
• Focused on maintenance of daily unbilled reports and departmental meeting benchmarks.

• Provided excellent customer service to policyholders, doctor’s offices, hospitals, Durable medical equipment vendors, and home care facilities
• Processed pre-certifications; verified ICD-9-CM and CPT procedure codes, verification of benefits—managed incoming calls in a call center
• Advised Medical Directors of appeals and forwarded contact information
• Prepared and completed daily action logs for appropriate follow-up and processing of requests promptly
• Review clinical notes for Surgical Orthopedic, Podiatry, Pain Management, and Durable Medical Equipment.
• Approve cases accordingly if criteria meet Oxford policy or forward matters to Medical Director for further review.