Summary
Overview
Work History
Education
Skills
LANGUAGE SKILL
Timeline
Generic

Mercedes Mayebe

Atlanta,GA

Summary

Dedicated healthcare professional with a strong background in Healthcare Management. Proven track record in driving operational efficiency and providing high-quality patient care. Skilled in strategic planning, team leadership, and building collaborative relationships with healthcare providers. Committed to achieving organizational goals and improving healthcare outcomes.

Overview

31
31
years of professional experience

Work History

Senior Lead AR Recovery Services

OPTUM360
02.2009 - Current
  • Responsible for reviewing, analyzing and resolving discrepancies in claim payments. Preparing, extracting, and submitting reports to internal management on status of outstanding medical bills and proposed and planned payment settlement details. Providing assistance, support, and resource to the team members to help identify reimbursement discrepancies and resolve issues. Contacting payers to discuss, negotiate payment and resolve outstanding medical bill accounts. Reviewing and interpreting payer contracts to ensure the accurate calculations. Working with payers verbal, online or/and written documentation by specific payor appeal processes for underpayments on claims. Identifying overpayment refund from payors. Identifying trends per payors
  • Reimbursement Specialist
  • Performing account follow-up and resolution of medical claims payments (Medicare Advantage Plan, Medicare, Medicaid, Commercial). Responsible for analyzing and adjusting of account balances after adjudication and payment postings. Monitoring payer’s performance and audits compliance of contractual obligations. Researching and allocate/post funds. Identifying trends per payer. Contacting payers to discuss, negotiate and resolve outstanding medical bills accounts. Fielding inbound self- pay calls and making outbound calls to patients in regards to their outstanding debts with the facility.

Claim/Customer Service Specialist - Bilingual (English/Spanish)

Robert Half Finance & Accounting
11.2007 - 02.2009
  • Responsible for providing services to customers and administrators to investigate, resolve, and provide information in response to inquires about claims, benefits (Medical, dental, & vision), eligibility, and complaints. Assisting with auditing, processing of all claims (Medical, dental, and vision), reviewing and adjusting all claims.
  • Medical Billing
  • Responsible for providing support to physicians’ office to handle claims review, research and solution (Medicare, Medicaid, and Commercial). Coordinating work flow and communication between the client and insurance carriers.
  • Spanish Educator – National Association of Incontinence
  • Providing customer care and communicating verbally and in writing in English and/or Spanish.

Data Analyst

Select Health of South Carolina
09.2005 - 04.2007
  • Reporting, analyzing, and tracking trends in medical utilization, access, cost, quality, outcomes and membership. Responsible for assuring the accuracy and validity of data and conducting analysis of data support conclusions or recommendations for action. Generating standard and ad hoc reports to support management of medical utilization, quality improvement, provider contracting, marketing initiatives, financial savings and cost reductions and statutory requirements. Extracting and summarizing data from database management systems used for measurement and decision support. Researching, testing, and validating results for accuracy.

Application Developer

Pathology Services Associates, LLC
08.2003 - 09.2005
  • Responsible for developing and maintaining of billing information interface, working closely with end-users, Internal staff, vendors, and other outside resources. Developing and supporting EDI (Electronic Data Interchange) interfaces and data conversions. Evaluating user requests, and assisting users to solve operating problems. Consulting with users to identify or develop operating procedures. Training users in program operation. Performing project, assignments and maintaining programming, and analysis.
  • EDI System Analyst
  • Responsible for formatting paper and electronic formats for all insurance types and transactions. Setting up new insurance carrier to include obtaining carrier specifications, Electronic Data Interchange enrollment, completing testing phases with carrier, and implementing formats to billing production. Developing and maintaining connectivity with direct to carrier or clearinghouse claim submissions

Statistical/Research Analyst III

Medical University of South Carolina
01.1995 - 08.2003
  • Gathering and reviewing a variety of narrative and/or statistical data to develop computer databases, preparing reports and conducting analysis of data support conclusions or recommendations for action. Receiving requests for information stored in the databases and making a determination as to whether requested information is obtainable and how long it will take to retrieve. Processing requests from computerized information that may be received from any health unit. Making recommendations to automate steps involved in processing and consolidating data.
  • Quality Improvement Coordinator/Clinical Review Specialist
  • Performing evaluation and coordination of clinical projects. Collecting and statistically analyzing data. Assisting and monitoring presentations of departmental projects to the Hospital Progress and Improvement Committee. Reviewing proposed plans for medical record documentation, invasive procedures reviews, and track appropriateness of surgical procedures for compliance with laws, regulations, standards, specifications or other requirements by the Joint Commission on Accreditation of Healthcare Organization (JCAHO). Assisting and developing critical pathways (Seizures, TIA, CVA, Craniotomy, and Laminectomy). Member of the task force to implement a performance improvement program to Autopsy Committee, Oncology/Transplant Interdisciplinary team, Risk/utilization Management, Safety/Environment Care, Radiology, Adverse Anesthesiology Events, Infection control, Medication Use Evaluation, and Medical Record Documentation. Performing Utilization Review – performing pre-certification of admissions to discharge planning on inpatient admissions. Using MS Office programming macros; to adapt, modify, implement and maintain programs, and creating databases and making presentations.

Education

M.A. - Computer Resources and Information Management

Webster University
12.2001

B.S. - Health Information Administration

Medical University of South Carolina
05.1993

Skills

  • UNIX system proficiency
  • Proficient in healthcare applications
  • Proficient in ASCX12N formats
  • Proficient in Windows software management
  • Skilled in SQL Server database administration
  • Analytical problem-solving
  • Multi-payer billing expertise

LANGUAGE SKILL

Proficient in written & spoken Spanish

Timeline

Senior Lead AR Recovery Services

OPTUM360
02.2009 - Current

Claim/Customer Service Specialist - Bilingual (English/Spanish)

Robert Half Finance & Accounting
11.2007 - 02.2009

Data Analyst

Select Health of South Carolina
09.2005 - 04.2007

Application Developer

Pathology Services Associates, LLC
08.2003 - 09.2005

Statistical/Research Analyst III

Medical University of South Carolina
01.1995 - 08.2003

B.S. - Health Information Administration

Medical University of South Carolina

M.A. - Computer Resources and Information Management

Webster University

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Mercedes Mayebe