Margaret Rita Goss
Summary
Experienced healthcare professional with strong background in processing and managing medical claims. Skilled in analyzing complex data, ensuring compliance with regulations, and resolving claims efficiently. Known for collaborative approach and adaptability, consistently delivering results in dynamic environment. Reliable team player with expertise in medical billing software, HIPAA regulations, and customer service.
Overview
21
21
years of professional experience
Work History
Authorization Specialist
Centene
Tampa, FL
01.2024 - Current
- Reduced processing times by effectively managing a high volume of authorizations.
- Maintained compliance with HIPAA regulations, safeguarding sensitive patient information during the authorization process.
- Prevented delays in care delivery by proactively identifying potential issues during the pre-authorization process and seeking clarification from providers when needed.
- Maintained full knowledge of current regulatory environment and made proactive adjustments to meet changing requirements.
- Collaborated with management to evaluate credit strategies and develop improvements.
Appeals Coordinator
Centene
Tampa, FL
11.2016 - 01.2024
- Acted as a departmental resource on appeals matters.
- Created, composed and maintained appeal response templates.
- Coordinated with senior specialist to compose appeal responses.
- Responded to attorney inquiries and litigation notices.
- Maintained comprehensive knowledge of regulatory guidelines to ensure compliance within the appeals department.
- Implemented process improvements based on audit findings, enhancing overall quality and efficiency within the department.
- Provided exceptional customer service by promptly responding to inquiries from appellants and other stakeholders.
- Developed strategic action plans to address identified issues, leading to a reduction in appeals backlog.
- Contributed to a positive work environment by sharing best practices among colleagues; improving overall team performance.
Appeals Claims Denial Specialist
Lakeland Regional Hospital
Lakeland, FL
07.2016 - 12.2016
- Maintained knowledge of insurance coverage benefit levels, eligibility systems and verification processes.
- Improved claim denial resolution by thoroughly researching and identifying root causes of denials.
- Optimized workflows within the team by assigning tasks based on individual strengths and expertise in particular payers or denial reasons.
- Streamlined communication between departments, facilitating faster resolution of denied claims.
- Documented medical claim actions by completing forms, reports, logs and records.
- Reduced aging accounts receivable balance with timely appeal submissions for denied claims.
- Conducted regular audits of denied claims, identifying areas for improvement in the revenue cycle process.
- Enhanced payer relationships by maintaining professional and effective interactions during the denial resolution process.
- Adjusted client accounts by entering discretionary billing items, requesting rebills and updating billing entity records.
- Contacted clients to collect information and communicate disposition of case, documenting interactions regarding eligibility, verification of benefits and claims payment status.
- Liaised with insurance companies to negotiate settlements for complex or high dollar-value denied claims, securing maximum reimbursement possible for the organization.
- Improved patient satisfaction by meticulously reviewing and appealing denied claims.
- Enhanced claims processing accuracy, rigorously verifying patient eligibility and benefit coverage.
Insurance Claims Specialist
Centene
Tampa, FL
08.2013 - 11.2016
- Answered CMR/ CORR/ FMT/ HOLDs claims inquiries via live transfer and resolve issues real time. Thoroughly researched post payment for professional and institutional and internal departments on data gathering and problem solving while investigating problems of an unusual nature. Presented propose solutions in a clear and concise manner . Process claims adjustments system and provided appropriate level of Root cause issues to ensure enterprise solutions and communicate findings . Assist in projects as assigned or needed
- Knowledge of HIPPA and Privacy , Health Care Reform , Affordable Health Care Act, Credentialing, NCQA , Medical terminology & billing & coding, Knowledge of Fee Tables , Bench Marks , Rate plans, DRG, Taxonomy, NPI, FFS,
- Knowledge of Professional & Institutional claims processing and adjustment experience in High Dollar Claims
- First contact Resolution and Root cause analysis experience experience Tier 1 and Tier 2 support identifying benefit load errors or provider contract load errors and opening service tickets
- Experience with proprietary software and Diamond (XCELLYS) based applications and platforms used to load provider contracts
- Enhanced customer satisfaction by efficiently managing insurance claims processes and providing timely resolutions.
- Maintained compliance with industry regulations and standards by staying current on relevant laws, policies, and best practices for handling insurance claims.
- Evaluated and settled complex insurance claims in strict timeframes.
- Maximized client retention by addressing concerns promptly and professionally, consistently demonstrating empathy and understanding during difficult situations.
- Facilitated smooth transitions between departments during claim handoff processes to ensure seamless coordination among internal teams for prompt resolution times.
- Sharpened professional expertise through continuous learning opportunities such as attending workshops, conferences, and pursuing industry certifications related to insurance claims management.
Key Account Manager
Advocate Consulting Group
Brandon, FL
04.2011 - 04.2013
- Built and maintained strong client relationships to drive business growth.
- Strengthened client relationships through regular communication and effective problem solving.
- Created sales forecasts to target daily, monthly and yearly objectives.
- Delivered exceptional customer service by resolving client concerns quickly and efficiently.
- Calculate premiums and establish payment methods.
- Operational support for high volume financial institutions.
- Provide managed employee benefits program and file quarterly tax documentation for clients.
- Review, research and negotiate insurance bills , health plan benefit packages and other contracts
Large Group Account Manager
Humana Inc
Tampa, FL
07.2004 - 08.2009
- Negotiated contracts with clients, securing favorable terms and conditions for both parties.
- Established effective reporting systems for performance tracking, enabling data-driven decision-making processes.
- Mentored junior account managers, fostering a culture of continuous learning and professional development.
- Worked effectively with senior-level clients such as executives to build trusting and long-lasting relationships with key accounts.
- Implemented strategic account plans for key clients, resulting in sales growth and improved profitability.
- Identified areas for process improvements, implementing changes that led to greater efficiency within the team.
- Provided exceptional customer service by promptly resolving issues and proactively anticipating client needs.
Education
GED -
Spanish American Civic Center For Adult Learning
Lancaster, PA07-1993
Skills
- Regulatory compliance
- Claims processing
- Authorization management
- HIPAA compliance
- Appeal resolution
- Insurance verification
- Process improvement
- Customer service
- Data analysis
- Problem solving
- Claims management
- Data entry proficiency
- Prior authorization processing
- Resource information
- Application assessment
Languages
Spanish
Native or Bilingual
Timeline
Authorization Specialist
Centene
01.2024 - Current
Appeals Coordinator
Centene
11.2016 - 01.2024
Appeals Claims Denial Specialist
Lakeland Regional Hospital
07.2016 - 12.2016
Insurance Claims Specialist
Centene
08.2013 - 11.2016
Key Account Manager
Advocate Consulting Group
04.2011 - 04.2013
Large Group Account Manager
Humana Inc
07.2004 - 08.2009
GED -
Spanish American Civic Center For Adult Learning
Similar Profiles
Noel BasnightNoel Basnight
Customer Service Advocate at CenteneCustomer Service Advocate at Centene
Johayri FelixJohayri Felix
Sales Support Administrator at CenteneSales Support Administrator at Centene
JASON KURMAN RN BSN RN-BCJASON KURMAN RN BSN RN-BC
Concurrent Review Nurse at CenteneConcurrent Review Nurse at Centene