Leondra Hilton
Spring,TX
Summary
Obtain a position where I can maximize my healthcare customer service ability, quality assurance, leadership skills and phone and computer experience.
Overview
13
13
years of professional experience
Work History
Medical Billing Specialist
UPRIGHT BILLING SERVICES
2022.09 - Current
- Claim submission: Prepare and submit claims to insurance companies for payment. This includes entering medical bill details into the insurance payer's required format.
- Payment posting: Record patient payments and ensure they are correct and align with the provider's records.
- Follow up on unpaid claims: Work with insurance companies to resolve issues and ensure timely payment.
- Answer patient inquiries: Help patients understand their insurance coverage and financial options.
- Maintain records: Keep accurate records of billing and collection activities.
- Generate reports: Create monthly reports to track billing and collection performance.
- Review contracts: Understand and interpret insurance payer contracts.
- Appeal claims: Review and appeal unpaid and denied claims.
- Manage accounts receivable: Manage accounts receivable reports.
- Assist patients with understanding their medical bills and provided clarification on complex insurance issues, promoting a positive customer experience.
- Communicate with insurance providers to resolve denied claims and resubmitted.
- Ensure timely submission of claims to various insurance carriers, resulting in prompt payment for services rendered.
- Examine patients' insurance coverage, deductibles, insurance carrier payments and remaining balances not covered under policies when applicable.
- Research CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
- Analyze complex Explanation of Benefits forms to verify correct billing of insurance carriers.
- File and update patient information and medical records.
- Ensure HIPAA compliance by adhering to strict confidentiality guidelines when handling sensitive patient information.
Utilization Management Coordinator 2
HUMANA
2018.07 - 2022.08
- Provides non-clinical support for the policies and procedures ensuring best and most appropriate treatment, care or services for member
- Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion.
- Contributed to the development of departmental goals, objectives, and performance improvement initiatives for continuous enhancement of services provided.
- Promoted a culture of continuous learning by conducting regular staff meetings focused on team collaboration and best practices sharing within the utilization management team.
- Reduced hospital readmission rates through thorough assessment of patient needs, developing appropriate post-discharge plans.
- Enhanced patient care by efficiently coordinating utilization management processes and reviewing medical records for case appropriateness.
- Streamlined communication process between nursing staff and case managers, reducing any delays in patient care plans.
- Collaborated closely with physicians to identify appropriate levels of care based on medical necessity criteria during admissions process.
- Maintained accurate documentation of all reviews, appeals, and decisions in line with organizational standards and requirements.
- Managed complex cases effectively, working closely with interdisciplinary teams to develop comprehensive care plans tailored to individual needs.
Recovery Resolution Analyst
UNITED HEALTHCARE
2015.01 - 2018.06
- Investigate claims to identify fraudulent claim submissions or aberrant billing practices
- Effectively handle their caseload, monitor mandated and internal turn-around time requirements
- Document in accordance with investigative standards, all investigative activity and findings in proprietary database
- Follow Department Standard Operating Procedures and Corporate Policies
- Perform analysis of claim data as needed
- Provide comprehensive reports of investigative findings when required
- Monitor the effectiveness of the investigative findings, for their Regions, making recommendations for flag addition, removal, or revision, to include Provider Education, Recovery or referral to GCA when appropriate
- Make claim payment / denial decisions based upon facts gathered during research of claims.
Pharmacy Technician/Prior Authorization Specialist
COVENTRY HEALTHCARE
2014.01 - 2014.12
- Handle inbound telephone and written inquiries from pharmacists and doctors regarding prior authorization by screening and reviewing requests based on benefit plan design, client specifics and clinical criteria
- Maintains complete, timely and accurate documentation of all approvals and denials
- Provide information to pharmacists and doctors regarding patients pharmacy benefit, drug coverage and provide accurate procedures for medication exceptions, Facilitate resolution of drug coverage issues and proactively address research and resolve issues while maintaining accurate and complete documentation of all inquiries for continuous improvement
- Work collaboratively with senior technicians, pharmacist, medical director and supervisor to ensure that best practices are shared
- Identify, research, and resolve payment discrepancies
- Print, download, and organize correspondence as necessary.
Pharmacy Technician
WALGREENS
2011.10 - 2013.06
- In accordance with state and federal regulations, assists the pharmacist, under direct supervision, in the practice of pharmacy in accordance with company policies and procedures
- Responsible for using pharmacy systems to obtain patient and drug information and process prescriptions
- Assists with and coaches pharmacy technicians in the operation of pharmacy systems and cashiers in the operation of the pharmacy cash registers
- Engages with customers and patients by greeting them and offering assistance with products and services
- Resolves customer issues and answers questions to ensure a positive customer experience
- Develops strong relationships with most valuable customers
- Reports, immediately, prescription errors to pharmacist on duty and adheres to Company policies and procedures in relation to pharmacy errors and the Quality Improvement Program
- Handles telephone calls that do not require personal attention of the pharmacist, including those to physicians
- Processes (corrects and resubmits) manual claims for third party program prescription services in a timely and efficient manner, and performs other clerical duties, as assigned by the Pharmacy Manager.
Education
ASSOCIATES OF ARTS DEGREE - HEALTH ADMINISTRATION
BROWARD COLLEGE
12.2018
DIPLOMA -
CHARLES W FLANAGAN
06.2008
Skills
- HIPAA compliance awareness
- Medicare, Medicaid and Commercial Plan Knowledge
- Claims Processing Proficiency
- Provider Support
- Medical Billing Proficiency
- Provider & Member Notifications(Approval & Denial)
- Benefit Enrollment
- ICD-10 Knowledge
- Prior Authorization Process
- Medical Appeals Handling
- Microsoft Office
- Compliance knowledge
- Medical Fraud Investigation
Volunteer Experience
Children Of Inmates Inc, I worked with the staff and a network of professional organizations reintroduce children to their incarcerated parents, create positive memories and moments for the children, and facilitate rebuilding lasting bonds for a lifetime. With the focus is raising children to be happy, healthy and productive citizens.
Timeline
Medical Billing Specialist
UPRIGHT BILLING SERVICES
2022.09 - Current
Utilization Management Coordinator 2
HUMANA
2018.07 - 2022.08
Recovery Resolution Analyst
UNITED HEALTHCARE
2015.01 - 2018.06
Pharmacy Technician/Prior Authorization Specialist
COVENTRY HEALTHCARE
2014.01 - 2014.12
Pharmacy Technician
WALGREENS
2011.10 - 2013.06
ASSOCIATES OF ARTS DEGREE - HEALTH ADMINISTRATION
BROWARD COLLEGE
DIPLOMA -
CHARLES W FLANAGAN
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