La'Shawn Barnes
Los Alamitos,CA
Summary
To excel in a challenging position in the healthcare industry. Utilizing my skills and knowledge in a pleasant professional working environment. Offering opportunities for advancement and potential growth.
Overview
25
25
years of professional experience
Work History
Claims Auditor
CalOptima
10.2014 - Current
- Conduct routine audits of processed claims to ensure they comply with federal, state, and internal guidelines, as well as the organization's policies and procedures. Key duties include evaluating claim processing for accuracy and adherence to regulations, researching claim errors, preparing reports for management, identifying systemic issues, and recommending corrective actions. Performing regular audits of both paper and electronic claims to verify adherence to CalOptima's policies, procedures, and regulatory guidelines.
- Verifying that claims processing, including payments and adjustments, aligns with federal, state, and internal standards. Investigating claim processing issues and errors to identify root causes. Preparing clear and concise written and oral summaries of audit findings and analysis for management. Spotting areas for process improvement within the claims department and recommending solutions or control measures. Facilitating the development of Corrective Action Plans (CAPs) to address identified deficiencies in the claims department. Applying and interpreting guidance from industry standards, regulatory bodies, and audit protocols to ensure proper procedures are followed. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Monitors and plans multiple concurrent audits and related projects; makes judgment calls around objectives and scope and ensures effective and efficient audit execution. Conducts mock audits of department functions using audit tools and develops corrective action plans to address any identified issues. Participates in workgroups that address both clinical and non-clinical internal activities for which CalOptima Health must demonstrate improvement to meet its contractual requirements with the CMS, DHCS, Department of Managed Health Care (DMHC) and any other applicable entity. Completes other projects and duties as assigned.
Claims Customer Service Lead and Claims Analyst
Keenan & Associates
09.2011 - 02.2014
- Provide customer service to clients, members and providers: Give benefits, handle questions, respond to complaints by telephone, fax or letter. Assist with supervisor calls and staff with escalated issues. Complete daily, weekly, monthly and quarterly reports for matrix. Adjust claims previously processed incorrectly, determine appropriate action for reversal and/or reprocessing, request refund if necessary, and compose and distribute any other necessary correspondence. Follow-up on pending claims, review claim reports and call logs to determine necessary action, request additional information as needed, bring closure to claims when requesting data has not yet been received. Adjudicate complex claims referred by Claim Approvers due to intricacy, multiple procedures and/or dollar limits. Respond to written Appeals using correct English and providing accurate information. Identify and process claims through Keenan vendors (network re-pricing, TPL).
Billing Specialist
Office Works @Long Beach Memorial Care
08.2010 - 09.2011
- Prepare and submit clean claims to various insurance companies either electronically or by paper. Answer questions from patients, clerical staff and insurance companies. Identifies and resolve patient billing complaints, prepare, review and send patient statements. Evaluates patient financial status and establishes budget payment plans. Follows and report status of delinquent accounts also prepare information for the collection agency. Perform daily backups on office computer system. Perform various collection actions including contacting patients by phone, correcting and resubmitting claims to third party payers. Processes payments from insurance companies and prepares a daily deposit. Appeals, CIF’s, TAR’s, CCS authorizations and adjustments.
Medical Auditor- CCS Certified and Informatics Specialist
Healthcare Resource Group @Allied Management Group
09.2008 - 07.2009
- Audit medical records for Inpatient, Outpatient, Emergency, and Urgent care claims using ICD, CPT, and HCPC, for HMO, PPO, Medicare, Medi-Cal. Audit level of care and drug management care, reduce level of care if needed, audit chief complaints, HPI, ROS, and physical exams. Audit labs and radiology medical records. Informatics Specialist includes medical coding methods (CPT, ICD, DRG, NDC) rules and regulations, and common business practices. Communication skills and advanced research skills.
Medical Coder, Biller, and CMA
Healthcare Resource Group @Premier Dermatology
06.2007 - 07.2008
- Billing and coding associate for PPO, HMO, Medi-Cal and Medicare claims, setting up provider contract with insurance companies, forward electronic claims to insurance companies, input check amounts, make sure correct fee schedules are paid, send medical records if needed, eligibility and benefits, authorization, billing patient for co pay and deductibles. Bookkeeping/accounting. Front office associate customer service rep, answering multiple calls from providers and members. Schedule appointments, verify insurance benefits and co pays. Corresponding through faxes, emails, and call backs. File charts back once complete, assist patient in the waiting room. Assist with Pre and Post op surgical procedures. Call in pharmacy prescriptions for patients.
Supervisor/ Claims, Member Service and Billing
Universal Care
08.2001 - 12.2006
- Third level claim examiner/adjuster, using ICD-9, CPT, HCPC, DRG, and NDC, for HMO, Medicare, Medi-Cal, and Pharmacy. Answering multiple calls from members and providers requesting claim status using CSC system, update employees, members and providers profiles, member benefits, appeals, student status, eligibility, check tracer, EOB, provider and member grievance, handle supervisor calls, attend corporate meetings, audits, physician referrals, insurance verification, dental and vision benefits, provider network, RX benefits using multiple screens and corresponding to call backs, faxes, and emails.
Second Level Claims Adjuster
PPO Next
05.2000 - 08.2001
- View local and national groups, individual credentialing applications, correspond via telephone, fax, and email with provider and administrative staff, provider CPT code discount allowed using Dynacomm, verify provider’s network, re-approaching of the problem claim for additional recommendation, corresponding with over 500 insurance companies, provider status, financial counseling, billing, claim status, physician referral and fee schedule.
Education
Medical Coding and Insurance Billing
Southeast ROP
Bellflower, CA01.2007
Medi-Cal Workshop
Long Beach Convention Center
Long Beach, CA01.2007
Medicare Workshop
Southeast ROP
Bellflower, CA01.2007
Cerritos College
Cerritos, CA01.1997
High School -
David Star Jordan High School
Long Beach, CA01.1995
Skills
- Supervisor and Lead
- General Knowledge of Microsoft Word, Excel, Access and PowerPoint
- IDX, Keane, EPIC, S&S, Onbase, Javelina, Facets, CAT
- 10 Key
- CPR Certified
Accomplishments
- Certificate of Completion
- HIPPA Certificates
- Regional Occupational Program, June 2007
- Certificate of Excellence in Medical Terminology, May 2007
- High Academic Awards, Cerritos College, 1995-1996
- Perfect Attendance Awards, Cerritos College, 1995-1996
- Medallion for High Academic, David Star Jordan High School, June 1995
Affiliations
- American Academy of Professional Coders (AAPC)
- American Associate of Medical Assistant (AAMA)
Timeline
Claims Auditor
CalOptima
10.2014 - Current
Claims Customer Service Lead and Claims Analyst
Keenan & Associates
09.2011 - 02.2014
Billing Specialist
Office Works @Long Beach Memorial Care
08.2010 - 09.2011
Medical Auditor- CCS Certified and Informatics Specialist
Healthcare Resource Group @Allied Management Group
09.2008 - 07.2009
Medical Coder, Biller, and CMA
Healthcare Resource Group @Premier Dermatology
06.2007 - 07.2008
Supervisor/ Claims, Member Service and Billing
Universal Care
08.2001 - 12.2006
Second Level Claims Adjuster
PPO Next
05.2000 - 08.2001
Medical Coding and Insurance Billing
Southeast ROP
Medi-Cal Workshop
Long Beach Convention Center
Medicare Workshop
Southeast ROP
Cerritos College
High School -
David Star Jordan High School