LaDonna Shore

Parallon/HCA - Brentwood, TN - August 2014 to August 2015; December 2015-September 2016;

December 2017-Present

Responsible for analyzing all credit balances and refunds in the cash management department, identify overpayments and process refunds to providers.

• Identify claims that have been incorrectly paid due to COB issues, reprocessed or corrected claim issues, provider errors, contractual errors and many other reasons that credit balances might exist.

• Work with insurance companies to verify that all outstanding refund issues have been addressed and solved.

• Work with providers and the practices to get any billing errors corrected

• Special projects as assigned by management.

• During my 5 years as Refunds specialist in the cash management department I have worked many different platforms within the refunds cash management team. I have worked as ECW refunds specialist, a Remedy resolution specialist, a PV UCC refunds specialist and an Unidentified Payment Specialist. I am very knowledgeable in all aspects of revenue cycle and overpayments.

• December 2017-December 2018 worked on the ECW team reviewing and resolving all credit balance issues within the ECW platform of providers. Reviewed and resolved patient, commercial and government credit balances along with resolving any assigned voided refunds that had been returned.

• December 2018-October 2019-I was transitioned to the Practice Velocity team working on credit balances within the urgent care centers platform. I reviewed and resolved both patient and insurance credit balances.

• October 2019-I was transitioned to the unidentified team within the Practice Velocity team. My duties were to resolve all unidentified payments that had been assigned to the unidentified team. These payments were assigned from various departments. My duties were to research these payments and resolve where the payments were coming from and where they needed to be posted to. There were many different type of payments issues that were involved with these payments. Missing EOB’s or remits, unidentified recoups, workers compensation or EPS payments that were not identified and unidentified patient payments were just a few of the unidentified payment issues that were researched on a daily basis. I work with several other departments to help resolve all types of unidentified payment issues. Since many of these payments are EPS and workers compensation payments I work very closely with those departments to get these unidentified payments resolved. As part of my review process I must research and analyze EOB’s, monthly utilization reports and other systems to assist in resolving these unidentified payments. Also in my position it is necessary to reach out to both payers and company accounts and request assistance resolving the payment issues. Once I have resolved the payments it is my responsibility to forward the correct information to the posting teams with the payment information.

• In this position I utilize and work in the following databases on a regular basis:

Unity, Onbase Thin and Thick, Artiva, Secret Server, Practice Velocity, ECW, Host, HEAL Utilization Reports, Passport, Diamond, CMT, and others as needed.

In this position I was responsible for reviewing all denied claims that had been resubmitted for payment. This included reviewing both appealed claims and claims that were on the second denial processes. It was my responsibility to review the claims, documentations, coding, contracts and analytics of the claim to verify if the claim should be paid or denied. It was my responsibility to make the final determination of approval or denial. If the claims met the approval process it was my job to process the claim to the correct department to insure that the claim was paid correctly. If the claim was denied it was my responsibility to inform the provider why I was denying the claim for the final time. It was also my responsibility to review and approve or deny claims submitted by claims analyst I. In this position I was the denial and appeals analyst for all rejected and disputed claims, this included government, commercial, transplants, auto and workers compensation. I was the senior analyst for all COB and subrogation claims.

In this position I was responsible for reviewing, analyzing and solving accounts for our clients that have credit balances. As an audit manager I helped our clients identify and solve over and under payments that exist on their accounts. I reviewed accounts both onsite and remotely as needed. As a regional account manager it was my job to work the accounts until the identified under payments have been collected and completely resolved for the client. In this position I was responsible for working with the staff of these accounts to insure all billing and claims issues are resolved. In this position I was the contact for all the accounts to notify of any payment denials and disputes that might be in question and it was my job to insure they were resolved to the provider’s satisfaction. As a regional account executive I use my many years of clinical and administrative healthcare experience to audit, analyze, identify and resolve incorrectly paid medical claims due to coding issues, COB, duplicate payments, reprocessed payments and many other contributing factors that result in incorrectly paid medical claims. A large part of my job was data analytics to identify over and underpayments

Researched overpaid claims and determine the current status of these claims

• Worked with providers to get these overpaid claims paid

• Various special projects as assigned by the management team

• Analyze various reports to identify overpayment issues

• Audited several databases on daily basis identifying overpayments, contractual errors and trends that were causing payment errors.

• Knowledgeable on most United Health Groups platforms and software's such as ODAR, TOPS, Lockbox, Tracr, Diamond, Oxford, Facets River Valley, Nice, ISET, IDRS, EDSS and various others.

As a member of the COB Audit team my primary job duties have included doing commercial COB auditing and healthcare contract auditing. I independently audited commercial COB and contract healthcare medical claims

These duties included analyzing claims and contracts, which included identifying, verifying, and starting the recovery process for any COB issues and incorrectly paid claims. I was responsible for reviewing Medicare and commercial insurance medical claims, which included ASO, PPO, and HMO LOB.

• Prior to the auditing my primary job was to assist the COB auditors by calling and verifying COB information from employers, providers, other insurance companies and long term disability carriers. Verifying this information was beneficial to the COB team as this is how the team was able to verify primacy for potential recovery claims that they had identified.

• As a United Healthcare Vendor we utilized many of the UHC systems.

• I also analyzed and help to develop reports that were used in trending and identifying possible recoverable claims.

• Additional duties were orientating and training all new COB support staff.

• I also wrote the COB training manual and policies and procedure manual that was used in training new COB auditors and support staff.

Supervisor for all the direct care staff, managed about 40 staff members

• Responsible for making sure all clients' needs are being met, directly responsible for about 75 clients on a daily basis. Providing assistance with social and medical needs.

• Do periodic in home visits to insure clients and direct care staff needs are being met

• Responsible for all HR duties of the branches from pulling the applications from Krono's to deciding which applicants were a good fit for the company and starting the interview process. I conducted the interviews and did the hiring of the new staff. I did all the prehire paperwork and conducted the 2 day orientations. Also responsible for making sure all the staffs' files were up to date and in compliance with state regulations.

• Responsible for approving all expense sheets including billing, travel and hours worked timesheets.

• As the Marketing Manager I was responsible for arranging all our marketing events for the Dallas branch. This included attending all networking events, making marketing visits to all hospitals, skilled nursing facilities, assisted livings and various rehab centers.

Responsible for the referral intake of all Case Management referrals

• Preliminary review of member's information to include, but not limited to, demographic information, utilization and other information that will assist in member's management

• Assign appropriate Case Manager telephonic or community-based) utilizing approved guidelines.

• Serve as a liaison between departments and operating units in the resolution of day-to-day administrative and operational problems

• Served as a liaison between external vendors, physician offices and other health plans and the Case Management department staff.

• Operate desktop computer and utilizes various programs such as Excel, Word, Outlook, responsible for all reports from Access database, reporting portals, claims, and case management.

• Was the first point of contact for any disputes that any members that were actively in case management might have. If I couldn't solve the problems then it went to a higher level. These issues included such things as claims disputes, issues getting medication assistance started for members that couldn’t afford their medications,

issues with any comorbidity the members might have. Any social issues such as homelessness, financial or medication needs.

Assist the Manager in ensuring that the unit is staffed appropriately

• Responsible for calling nurses and/or nurse technicians to assist with staffing needs.

• Assist the Case Manager and Social Worker with discharge planning through research of various facilities

• Coordinate exchange of information to facilitate the referral process when sending the patients for an outpatient procedure

• Assist the department in keeping track of insurance updates and concurrent reviews are sent on a timely basis

• Responsible for notifying the members of the interdisciplinary team regarding transportation and patient referrals outside of the facility

• Review appropriate procedure coding assignment, along with the Case Manager, for appropriate reimbursement.

• Responsible for doing all insurance verifications to get the patients approved for admission.

• Responsible for presenting the patients before the medical review board to insure that they meet medical necessity to be admitted to the hospital.