Karmen Davis
Pittsburgh,PA
Summary
Motivational leader and organizational problem-solver with advanced supervisory, team building and customer service skills. Experience stepping into roles and quickly making positive changes to drive company success. Focused on using training, monitoring and morale-building techniques to maximize employee engagement and performance. Experienced Resource Analyst with intensive experience of working in healthcare insurance industry; in various domains e.g. Managed Care contract negotiations, Medicaid contracts and renewals, Billing & Reimbursement. Extensive experience in responding to inquiries, requests and issues, analyzing and interpreting eligibility, benefit trends claims, and pricing issues with payers. Excellent experience of renegotiating and initiating various Medicaid contracts and renewals, addressing contract and rate issues with various insurance companies or payers, analyzing managed care contracts and reconciling payment. Efficient in developing and tracking key performance indicators; and conducting ad hoc analysis of specific managed care issues, overseeing ongoing analysis of all account-based reimbursement of claim transactions for accuracy. Strong experience of reviewing and reconciling extensive and complex financial and operational analysis of managed care contracts and proposals. Reviewing and approving accounts for adjustments and refunds. Proficient in handling monthly billing, accounts receivable investment, cash flow, general month end closing processes, and audit management, monitoring daily A/R revenue, Adjustments, Billing, and Pricing issues. Experienced in establishing and maintaining working relationships with Hospital Providers and well as independent physicians.
Overview
32
32
years of professional experience
Work History
Manager of Provider Relations
Highmark Blue Cross Blue Shield
Pittsburgh, PA
12.2015 - Current
- Act as a key resource to external providers and internal key stakeholders as it pertains to operational issues impacting assigned network segment.
- Responsible for day-to-day business activities and managing provider relationships.
- Develop and implement educational processes and pro-active solutions for payment and other provider operations requirements as well as access & availability concerns
- Reviews reports on annual provider satisfaction surveys; ensures the development of plans to improve identified areas of concern; work with other departments to develop quality assurance initiatives based on survey results.
- Ensure segment’s data integrity of provider directory, web search, etc.,
- Monitor/Trend Provider calls received as well as any complaints received for responsible segment
- Develops processes to educate new and existing providers regarding their contractual responsibilities as well as policies and procedures.
- Monitor provider concerns, collaborate and consult with internal leaders and department to improve operations and resolve issues impacting provider satisfaction and payment.
- Participates in cross-functional workgroups to understand impact of plan changes and initiatives on provider network, advocating for providers as appropriate
- Ensure timely responses to regulatory agencies (DOI, CMS, DHS) in response to all Provider Network regulatory and compliance issues
- Facilitate with marketing and retention department management to identify opportunities in current provider locations and cultivate them in viable prospects to increase Highmark enrollment and retention efforts.
- Coordinate events with the community/government agency offices within assigned network
- Working collaboratively with the Provider Account Management Team, build strong partnership with provider community by cultivating open communication and ensuring Account Leads are aware of provider pain points relative to claims disputes.
- Attend Joint Operating Committee meetings and takes ownership of resolving issus with assigned hospitals, etc.
- Develops policies and procedures, process improvement initiatives
- Manage and mentor staff to ensure job functions are completed appropriately and according to priorities
- Coordinates department’s efforts with those of other departments
- Responsible for communicating and working with providers and various medical billing staff to address billing and various reimbursement methodologies.
- Investigated claims issues and make recommendations for process improvement, contracts or enhancements to system configurations
- Understand insurance carrier guidelines and stay abreast of any changes that occur to communicate them to management and staff
Business Office Lead
HarmarVillage Care Center
Cheswick, PA
02.2015 - 12.2015
- Analyze accounts and accounts receivable, including supervising resident trust funds
- Manage employees from training to counseling, including discussing benefit programs and how to handle confidential data
- Ensure proper claims, billing and tracking of operating costs through management of office staff and policies
- Responsible for ensuring that the facility's bills are paid and remittances and other payments are received, as well as claims creation and ongoing management of the budget to ensure financial growth and patient admissions.
Billing / Reimbursement Analyst
Accredo Health Group via US Tech Solutions
Warrendale, PA
07.2014 - 02.2015
- Managed day-to-day operations to ensure strong accounts receivable processes to grow revenue and minimized risk and maximize claim payments
- Work with cross functional leadership teams including sales, account management, operations, and treasury to ensure maximum cash flow and minimized risk
- Assisted clients and account managers with resolving complex issues impacting cash flow
- In charge of monthly billing, accounts receivables, general month end closing, and audit management
- Represented specialty claim billing and reimbursement departments in cross-functional meetings and projects
- Assist with the implementation and communication regarding to new corporate initiatives and processes.
Senior Intake / Resource Analyst
ZOLL
07.2012 - 07.2014
- Performed a full range of professional resource analyst assignments in a full-functioning capacity
- Renegotiated and initiated various Medicaid contracts and renewals
- Addressed contracting and rate issues with various insurance companies or payors
- Reviewed and Reconciled extensive and complex financial and operational analyses of managed care contracts and proposals
- Oversaw ongoing analysis of all account-based reimbursement transactions for accuracy
- Analyzes managed care contracts and reconciles payments received
- Contact insurance companies and various Medicaid state plans to have adjustments processed if payments are not in accordance with the contract
- Make recommendations to Directors and other Leaders prevent future cash losses
- Provides financial data analysis to assist Facility in Managed Care contract negotiations
- Identify claims and reimbursement related system problems, including claims coding and bill processing issues, and implement and monitor system modifications to ensure resolution
- Relied on experience and judgment to accomplish responsibilities, worked under minimal supervision, utilized various resources, contacts to perform job, and direct the work of others
- Developed and tracked key performance indicators; and conduct ad hoc analyses of specific managed care issues
- Work with managed care staff both in Multi-State Divisions
- Served as a representative of ZOLL to managed care to payers in all markets
- Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to internal and external physicians and facilities on a day to day basis
- Work hand in hand with ZOLL’s Contracting Attorney and the Director of National Accounts to identify and resolve contracting issues
- Assist Regional and Territory Managers with various compliance issues and medical criteria regarding Medicaid and making a final determination of fitting the patient for the LifeVest
- Recruited and Trained Territory Managers regarding proper identification of the Medicaid Pending & Collections Process with new and existing patients
- Established working relationships with hospitals and physicians across the country that may be involved with ordering the LifeVest
- Educated Hospital Administrations as to how the Medicaid Pending process is utilized at ZOLL and how it benefits for both the patient and hospital.
Insurance Collection / Reimbursement Supervisor
CVS Caremark
01.2009 - 01.2012
- Responsible for recruiting and training a staff of 20 – 30 employees and the daily workflow to ensure excellent customer service and to monitor the Insurance Receivable metrics for both Government and Non-Government payers to ensure company profitability
- Analyze and interpret eligibility, benefit trends and pricing issues with payers
- Supervises daily activities to ensure that productivity objectives are met, including individual and team performance goals
- Monitors the performance of staff members to ensure compliance with operating procedures and standard practices
- Document, monitor, and evaluate performance measures which include phone system reports, assigned aging, and end of the month reports
- Develops and update operating procedures to facilitate efficient operations
- Responds to inquiries, requests and issues when situations get escalated to a higher level of authority
- Coach and mentor staff, including the administration of corrective actions, recognition / rewards, and performance review process
- Monitoring and approval of associate time off through the Paid Time Off Bank Tracker and time keeping system
- Tracks industry trends and changes among healthcare payers
- Confirm and review daily reporting of current A/R and weekly reports to forecast trending in the current receivables
- Knowledgeable of Medicare, Medicare Replacement, Medicaid and Commercial payers
- Track, Monitor and Drive Government claims to insure department remains in compliance
- Assist with training of existing Staff, Managers and Employees and development and revision of department processes/procedures
- Managed staff; assigns work, develops work schedules, instructs in proper procedures
- Monitored staff performance and provides feedback to identify areas of improvement
- Insure staff is obtaining adequate information and provided opportunity for associated training for staff
- Provide daily, on-floor support to operational teams
- Worked closely with Process and Quality Monitoring & Regulatory teams to communicate changes in policies, procedures, systems enhancements, and new drug product information
- Monitor daily Accounts Receivable revenue, Adjustments, Billing, and Pricing issues for accuracy
- Review and approved accounts for adjustments and refunds.
District Manager – Eligibility Services
MedAssist Inc.
01.2008 - 01.2010
- Recruiting and Management of 30+ employees within the district and call center office as well as those that work onsite at local hospitals
- Implemented new regulations to assist various hospital administrators with new contracts or projects
- Prepare and present client reports
- Train new and existing staff on new procedures / processes
- Assist in providing support and continued education to on-site staff and hospital administration
- Provide access to systems and databases required for employees’ daily functions
- Reviewed daily census to determine daily work flow, sales and revenue reporting
- Audited all admission and re-admission documents obtained and forwarded by the facility admissions coordinators for completeness
- In charge of hiring, reviewing monthly and yearly performance and corrective action for all employees
- Oversaw and responsible for driving overall Accounts Receivable and Revenue for the district
- Maximize and expedited hospital recovery potential of Medicaid revenue by assisting uninsured and underinsured patients to complete the process of applying for state governmental benefits such as Social Security Disability, Medicaid and Medicare
- Implemented one-on-one advocacy services to patients and PSR’s to help them identify and establish entitlement to benefits
- Accompany patients or providers as an advocate or stand-in for interviews or hearings with government agencies
- Staff and represent patient's and hospital's interests in administrative fair hearing proceeding to contest unjust denial of benefits
- Utilized various techniques including skip tracing methods or professional contact with patients to enhance our effectiveness in communicating with indigent populations.
Insurance Claims Team Lead
Golden Living Centers - Central Billing Office
Pittsburgh, PA
01.2005 - 01.2008
- Oversaw billing and collection of private insurance claim receivables for a group of facilities in the central billing environment
- Processed claims within the parameters established by company policies and third party billing requirements, and necessary to achieve reasonable collection goals
- Served as a mentor / trainer for new and existing employees
- Reconcile census to billing; correct billing errors and notified admissions as well as communicate this info to the nursing staff
- Monitors private accounts receivable balances and took progressive and aggressive collection action to ensure timely payment, within the parameters established by company
- Resolved billing errors and processes refunds for resident overpayments in accordance with established business office policies and procedures
- Reviews all admission and readmission documents that were obtained and forwarded by the admission coordinator for completeness
- Worked hand in hand with the admissions coordinator or resident’s agents to obtain additional or missing information for billing purposes
- Establish and maintain master files for all new admissions in the billing system and revenue generation
- Review daily census activity and oversaw payer status changes to communicate to billing specialist.
District Operations Supervisor
Kelly Home Care
Pittsburgh, PA
01.2004 - 01.2006
- Oversaw and managed all 327 ISC staff including hiring, reviewing performance and implemented appropriated action when performance issues needed to be addressed
- Act as administrator in the absence of the District Manager
- Acting as quality coordinator of KQMS (Kelly Quality Module Systems) initiatives for the district
- In charge of making final decisions regarding the acceptance of clients on evaluation of available payment sources
- Effectively managed workers compensation, unemployment claims for the district by working closely with the applicable corporate departments to control cost
- Managed and oversaw the processing of payroll, accounts payable / receivables for all locations within district which includes ensuring timecards were submitted to corporate were accurate
- Manage district back office operations, supervised account receivables, collections and served as the computer super user for the district
- Oversaw and Implemented sales and marketing activities in order to target a profitable client base
- Responsible for the recruitment all staffing and hiring of qualified candidates to staff lines and geographical service areas within the assigned locations
- In charge of scheduling, orientation, and opening of new cases, processing of all new and existing client information as well as updating database information.
Utilization Review & Claims Manager
Cigna Healthcare
Pittsburgh, PA
01.2001 - 01.2004
- Managed Cigna Tel-Drug Injectable process as well as the Infertility and Orthotics Unit
- Oversaw training for the entire department
- Established workflows in order to meet company guidelines and various Federal and State mandates
- Assist Case Managers with research and identify specific insurance issues regarding cost benefit analysis and benefit interpretations
- Acting liaison between Intracorp and the Cigna claims offices and Clinical Resource Units (CRU)
- Manage day to day account activities and served as liaison between hospitals and customers
- Utilized superior customer service skills to educate and explain the services requested and obtained by members
- Verify patient eligibility and appropriate benefit determinations in clinical scenarios
- Interpret benefit plan language by demonstrating the knowledge of benefit and clinical exceptions based on Federal and State Mandates the may override criteria in certain funding situations
- Initiate, coordinate and follow-up with Registered Nurses and Physicians in regards to certifiable days for the patient and achieving care and cost effective treatment plan
- Very knowledgeable of ICD-9 / CPT, HCPCS and Revenue Coding
- Identified and resolved workflow issues by proactively seeking opportunities to expedite, streamline and enhance customer service
- Served as Mentor / Trainer of all new employees and employees that were temporarily or contractually assigned.
Lead Billing Specialist
UPMC HEALTH SYSTEM – Patient Business Services
Pittsburgh, PA
01.1999 - 01.2001
- Facilitator for third party healthcare claims, collections and reporting
- Detailed knowledge of ICD-9 / CPT coding, medical terminology and various forms used for medical billing such as HCFA 1500, Universal Claim Forms and UB
- Monitored third party payments, adjustments as well as edit outgoing claims to insure claims were clean and without errors before being electronically billed
- In charge of training new employees to the department
- Processed medical billing transactions, maintained accounting records, billed primary, secondary and tertiary payers
- Thorough understanding of HMO, POS, PPO, Indemnity and other plan type coverage and plan language
- Extensive background with the coordination of benefits, subrogation, Medicare and various state Medicaid programs.
Senior Benefits Representative – Team Lead
UNITED HEALTHCARE
Pittsburgh, PA
01.1995 - 01.1999
- Assist with coaching, mentoring and training a team of 35 call center / claims employees
- Responsible for the administration of benefit plans and communicating directly with clients, employees, and benefit offices via telephone, email or facsimile
- Process HCFA 1500 and UB-92 claim forms from various providers while adhering to strict deadlines set forth by the company, reduce cost and enhance productivity standards
- Utilized medical terminology such as ICD-9 and CPT coding
- Worked as a team leader by assisting team members with information and training regarding plan enhancements or exceptions
- Acting liaison for employers and other corporations that had contracts and policies with the company
- Served as a call monitor / coach for the Quality Assurance Department
- Served on the Peer Review Board to recognize outstanding achievement of employees for the company
- Utilized one on one call coaching methods to improve and maintain company standards.
Senior Benefit Analyst
CIGNA GROUP INSURANCE
Pittsburgh, PA
01.1992 - 01.1995
- Administered and counseled employees regarding Leave of Absence processes
- Determined employee eligibility in relation to sick leave, the Family Medical Leave Act (FMLA), short-term disability and long-term disability
- Ensured that all records and updates are properly documented and communicated to necessary personnel
- Advised employees on benefits-related issues, such as medical, dental, vision, and life insurance, flexible spending accounts and retirement benefits
- Delivered new hire benefits orientation and acts as a liaison with the company's benefits vendors
- Responsible for responding to and/or resolving employees’ benefits questions and problems, processing benefits transactions, communicating with health insurance vendors regarding eligibility and other benefit / membership issues, utilized PeopleSoft to process information related to benefits, conducted benefits orientations, managing benefits and underwriting documentation.
Education
Major: Hospital Administration Minor: Database Programming
Community College of Allegheny County / University of Pittsburgh Parallel Program
Computer Information Science - Database Programming
International Academy of Design and Technology
Skills
- Proficient in MS Office – all products
- Medicare/ Medicaid Guidelines and Regulations
- Managed Care contract negotiations
- Medicaid / Medicare contracts and renewals
- Member Eligibility
- Accounts Receivable revenue
- Claim Processing & Adjustments
- UB 92 and HCFA 1500 Billing, Pricing
- Workflow Analysis
- Provider Relationship Management
- Revenue Forecasting
- Policy Administration
- Project Planning
- Fiscal Management
- Business Administration
- Staff Management
- Process Improvement
- Team Development
- Performance Evaluations
- Work Planning and Prioritization
- Team Leadership
- Administration and Reporting
- Hiring and Training
- Staff Development
- Managing Operations and Efficiency
- Negotiation and Conflict Resolution
- Customer Relationship Management
- Strategic Planning
- Financial Management
- Business Analysis and Reporting
- Problem Resolution
- Technical Proficiency
- Training and Development
- Teamwork and Collaboration
- Goal Setting
Timeline
Manager of Provider Relations
Highmark Blue Cross Blue Shield
12.2015 - Current
Business Office Lead
HarmarVillage Care Center
02.2015 - 12.2015
Billing / Reimbursement Analyst
Accredo Health Group via US Tech Solutions
07.2014 - 02.2015
Senior Intake / Resource Analyst
ZOLL
07.2012 - 07.2014
Insurance Collection / Reimbursement Supervisor
CVS Caremark
01.2009 - 01.2012
District Manager – Eligibility Services
MedAssist Inc.
01.2008 - 01.2010
Insurance Claims Team Lead
Golden Living Centers - Central Billing Office
01.2005 - 01.2008
District Operations Supervisor
Kelly Home Care
01.2004 - 01.2006
Utilization Review & Claims Manager
Cigna Healthcare
01.2001 - 01.2004
Lead Billing Specialist
UPMC HEALTH SYSTEM – Patient Business Services
01.1999 - 01.2001
Senior Benefits Representative – Team Lead
UNITED HEALTHCARE
01.1995 - 01.1999
Senior Benefit Analyst
CIGNA GROUP INSURANCE
01.1992 - 01.1995
Major: Hospital Administration Minor: Database Programming
Community College of Allegheny County / University of Pittsburgh Parallel Program
Computer Information Science - Database Programming
International Academy of Design and Technology
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