Khalialah Vernoy
Hanover Park,IL
Summary
Highly-motivated employee with desire to take on new challenges. Strong worth ethic, adaptability and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new things.
Overview
24
24
years of professional experience
Work History
Clinical Appeals Nurse
United Healthcare
Telecommute
01.2019 - Current
- Perform initial assessment of appeals cases to determine next steps.
- Review applicable medical records and create clinical review summaries.
- Assessed the patient's situation, including every detail related to the insurance claim, its denial, and the treatment to be received, before deciding whether or not to move forward with the appeals process.
- Take appropriate steps based on case determination by the Medical Director or Nurse (e.g., denial upeld, overturned, dismissed, pended for additional action).
- Review and evaluating appeals in compliance with state and federal mandated turn around times and process requirements.
- Ensured that all documentation was accurate and up-to-date according to established guidelines.
Charge Capture Nurse
Loyola University Medical Center
Maywood, IL
04.2015 - 04.2019
- Performed reviews of medical charts.
- Performed external and internal medical auditing.
- Validated both the coding accuracy and appropriateness of services given to inpatients.
- Recorded audit determinations using an audit tracking system to create a narrative explaining the rationale behind the care given to patients.
- If an appeal arises, be able to supported findings.
- Consulted with physicians, patients, and other staff as needed.
- Assisted with quality assurance functions such as development of coding guidelines as needed
- Maintained all required certifications to ensure ability to perform audits.
Pre-Certification Specialist
Loyola University Medical Center
Maywood, IL
05.2004 - 06.2011
- Conducted pre-certification process for medical procedures and services to ensure compliance with insurance requirements.
- Analyzed patient information, benefit coverage details, and other pertinent data to determine eligibility for benefits.
- Reviewed claims denials from insurance companies and worked with providers to resolve issues in a timely manner.
- Identified trends in denials and rejections due to incorrect coding or lack of documentation.
- Adhered to HIPAA regulations throughout entire process.
Medical Biller
Loretto Hospital
Chicago, IL
09.2001 - 05.2004
- Reviewed patient insurance information to ensure accuracy and completeness of claims submission.
- Verified medical codes for diagnosis, treatments, procedures and supplies using ICD-9 coding system.
- Compiled and processed data for billing purposes utilizing billing software programs.
- Submitted electronic claims to various insurance carriers.
- Maintained up-to-date knowledge of government regulations related to healthcare reimbursement policies and procedures.
- Answered incoming calls regarding billing inquiries from patients and and or providers in a professional manner.
- Researched discrepancies between billed charges and payments received from insurance companies or other third party payers.
- Performed follow up activities on unpaid claims with insurance companies or other third party payers by phone or written correspondence.
Education
Certified Professional Biller CPB - Medical Insurance Billing
AAPC
Hanover Park, IL06.2021
Certified Professional Coder CPC - Medical Insurance Coding
AAPC
Chicago, IL09.2018
Bachelor of Science - Nursing
Resurrection University
Chicago, IL04.2015
Skills
- Medical Chart Management
- Clinical Documentation
- Electronic Health Records Management
- Decision-Making
- Compliance Monitoring
- Indirect Patient Care
- Oral and Written Communication
- Patient Record Review
- Clinical Recommendations
- Certified Professional Biller (CPB)
- Certified Professional Coder (CPC)
Timeline
Clinical Appeals Nurse
United Healthcare
01.2019 - Current
Charge Capture Nurse
Loyola University Medical Center
04.2015 - 04.2019
Pre-Certification Specialist
Loyola University Medical Center
05.2004 - 06.2011
Medical Biller
Loretto Hospital
09.2001 - 05.2004
Certified Professional Biller CPB - Medical Insurance Billing
AAPC
Certified Professional Coder CPC - Medical Insurance Coding
AAPC
Bachelor of Science - Nursing
Resurrection University
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