LORETTA JUNE MOELLER
Elsa
Summary
To secure a position as a Senior Claims Examiner Professional utilizing my administrative, marketing, and interpersonal skills with accuracy and efficiency while maintaining a motivated, productive, and goal-oriented environment for the entire professional team on board while maintaining extensive customer loyalty.
Overview
15
15
years of professional experience
1
1
Certification
Work History
SENIOR CLAIMS EXAMINER / BUSINESS ANALYST
GRAVIE, LLC
03.2019 - Current
- Provide superior claims services to clients
- Manage claims from inception to resolution
- Prepare written status reports quarterly, as needed
- Attend file reviews, when requested
- Investigate and determine compensability of claims
- Gather and analyze information including medical, legal, and factual evidence to determine compensability of claim
- Set up medical evaluations for delayed claims and refer for legal evaluations
- Issue decisions regarding claim compensability
- Manage diary, mail, phone calls, and other tasks to move claim to the best financial outcome and timely resolution
- Monitor benefits payments and notices to ensure timely issuance
- Review medical claim reports to ensure appropriateness of treatment
- Set medical, legal, vocational rehabilitation, and indemnity reserves based on facts of case and full potential exposure including reporting to excess carrier
- Provide support for litigation and subrogation claims including court hearings
- Communicate and strategize with legal counsel regarding issues such as discovery, depositions, settlement value
- Investigate and identify liable third party; file claim in appropriate venue and jurisdiction within statute of limitations
- All other duties as assigned or as situation dictates
- Reports for work on time and maintains a satisfactory attendance record.
- Start up Company experience.
- Auditor of all claims processed
- Monthly.
Patient Financial Representative
Gillette Children’s Specialty Healthcare
09.2018 - 03.2019
- Works closely with Gillette patients and families to help them resolve their self-pay balances; set up payment plans
- Work closely with the collection agency on transferring and monitoring bad debt patient accounts.
- Independently manages day to day workload.
- Adheres to Gillette Children’s Specialty Healthcare policies and procedures.
- Collaboratively works with other departments to find resolution to issues, questions, concerns and then takes appropriate action.
- Problems not able to be resolved promptly was referred to Patient Accounting Manager
- Excellent verbal and written communication skills
- Willingness and adaptability to learn and implement new and/or different processes and procedures.
- Ability to independently initiate, research, analyze, and offer suggestions and support to department.
- Submission of claims in a timely manner
- Identify issues with accounts from Explanation of Benefits and Denials
- Check each insurance payment is for accuracy and compliance with contract discount
- Call insurance companies regarding any discrepancy in payments if necessary
- Identify and bill secondary insurance
- All accounts are to be reviewed for insurance or patient follow-up
INSURANCE ACCOUNT REPRESENTATIVE
PROFESSIONAL SERVICE BUREAU
05.2017 - 08.2018
- Review patient bills for accuracy and completeness and obtain any missing information
- Submission of claims in a timely manner
- Identify issues with accounts from Explanation of Benefits and Denials
- Check each insurance payment for accuracy and compliance with contract discount
- Call insurance companies regarding any discrepancy in payments if necessary
- Identify and bill secondary insurance
- All accounts are to be reviewed for insurance or patient follow-up
- Answer all insurance telephone inquiries pertaining to assigned accounts
- Conduct status checks with insurance companies and determine if appeal process is available
- Complete file/account documentation
PSR SUPERVISOR/ COORDINATOR
RETINA CENTER
01.2017 - 03.2017
- Oversee day-to-day work of Patient Service Representative functions for seven locations and 10 employees
- Ensure accurate, timely, and complete demographic and financial information was gathered and entered into system correctly and in a timely manner.
- Assist with research and create recommendations to maximize patient experience, and streamline day-to-day operations to improve financial performance as needed.
- Support and assist in department function as needed based on volume and workload.
- Comply with all federal, state, and Joint Commission requirements.
- Created a work environment for employees through team building, coaching, constructive feedback, work delegation, personal example and goal setting that encourages creativity, open dialogue on work issues, professional growth, and a consistent, high level of performance; encourage and support employee decision-making within his or her scope of responsibilities.
- Deliver positive patient experience.
- Perform any special assignments as requested
REIMBURSEMENT SPECIALIST / BILLING COLLECTIONS Team Lead
DONJOY ORTHOPEDICS
03.2015 - 01.2017
- Review and submit initial billing invoices to appropriate 3rd party payers, validating eligibility requirements, and, ensuring that appropriate account information is received to guarantee maximum reimbursement in a timely manner.
- Appeals , denials, claims resubmission, Self Pay Accounts
- Identifying coding errors within the system, as well as working referrals and authorizations, requesting of Medical Records, meeting and exceeding production standards set on a daily basis.
- Perform follow –up and collections of client accounts, including telephone calls and online inquiries with 3rd party payers
- Monitor daily billings, collections, and outstanding claims submitted to carriers
- Research and appeal denied claims along with correcting errors for claim resubmissions
- Ensure client responsibility balances are accurate, as well as setting up Self Pay Payment Options
- Heavy phone calls Insurance Carriers – Attorneys- Our Clients and /or patients
- Printing and working off of current LCD's to process Medicare and Medicare Supplement Plans
- Identifying coding errors within the system
- Working with staff / coworkers to educate regarding Referrals / Authorizations
- Utilizing Right Fax on a daily basis
- Daily production / keeping track of money collected on a daily basis
- Credit invoices to be reprocessed
- Requesting of Medical Records and other supporting documentation as needed.
- Soft collections.
- Team Lead and fill-in Manager when needed
MEDICAL CLAIMS EXAMINER
Ucare/ADKORE STAFFING GROUP
10.2014 - 03.2015
- Maintained claim files, records of settled claims and inventory of claims requiring detailed analysis, as well as resolving complex claims issues using high service oriented claims filing.
- Report of overpayments, underpayments and other irregularities of processed claims when needed by contacting claimants, doctors, medical specialists, or employers to get additional information when needed in processing of their medical claims.
BILLER
BEACON ACCOUNTS MANAGEMENT
02.2014 - 10.2014
- Fluent knowledge of insurance guidelines, especially Medicare and state Medicaid policies, along with highly effective claims processing by entering codes and charges in to the computer system to bill utilizing HCFA 1500 claim forms by sending them EDI or as a paper claim submission when needed.
- Reviewed patients bills for accuracy and completeness to obtain any missing information where needed.
- Followed up on unpaid claims within standard billing cycle timeframes, answered heavy phones, responded timely to voicemails and emails
TUTOR
NATIONAL AMERICAN UNIVERSITY
12.2010 - 10.2014
- While attending school at National American University I became a tutor that was responsible for helping students with understanding their weekly assignments, teaching online navigation, and helping with other tasks for Learning Services / Mass Mailings.
- Attended the front desk, receiving calls and directing to the appropriate personnel while providing expertise, experience, and encouragement to students.
Education
A.A.S OF HIT - undefined
NATIONAL AMERICAN UNIVERSITY
11.2013
CODING DIPLOMA - undefined
NATIONAL AMERICAN UNIVERSITY
05.2012
Skills
- Revenue Cycle
- 5 plus years’ experience
- Team Building
- Strategic Planning
- Staff Engagement & /Retention
- In depth knowledge of claims processing
- Medicare & Medicaid Reimbursement
- Training & Policy Development
- Leadership
- Customer Service
- Cost Reduction
- Very detail oriented
Certification
New York Health Adjuster Liscense
Training
Supervisor Development, Coordination of Benefits, Workers Compensation, Medical Terminology, Third party Liability, Project Management, ICD9/ICD10, Availity, Procedure Codes, 10 keys, Presenting and Selling Your Ideas, Emdeon EDI, Outbound Call System, Selecting the Best Candidate, DME, Effective Management, Adjustments, Electronic Medical Records, Coding, SOP Standard Management, Zirmed, MDI, Advanced MD, Office Outlook, Excel Reports, Soft Collections
Timeline
SENIOR CLAIMS EXAMINER / BUSINESS ANALYST
GRAVIE, LLC
03.2019 - Current
Patient Financial Representative
Gillette Children’s Specialty Healthcare
09.2018 - 03.2019
INSURANCE ACCOUNT REPRESENTATIVE
PROFESSIONAL SERVICE BUREAU
05.2017 - 08.2018
PSR SUPERVISOR/ COORDINATOR
RETINA CENTER
01.2017 - 03.2017
REIMBURSEMENT SPECIALIST / BILLING COLLECTIONS Team Lead
DONJOY ORTHOPEDICS
03.2015 - 01.2017
MEDICAL CLAIMS EXAMINER
Ucare/ADKORE STAFFING GROUP
10.2014 - 03.2015
BILLER
BEACON ACCOUNTS MANAGEMENT
02.2014 - 10.2014
TUTOR
NATIONAL AMERICAN UNIVERSITY
12.2010 - 10.2014
A.A.S OF HIT - undefined
NATIONAL AMERICAN UNIVERSITY
CODING DIPLOMA - undefined
NATIONAL AMERICAN UNIVERSITY
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