Michelle Camerlin
Warwick,RI
Summary
To use my extensive training and experience in medical billing and customer service to develop and further my career of providing excellent service to providers
Overview
31
31
years of professional experience
1
1
Certification
Work History
Senior Appeals Representative Medicare and Retirement
UnitedHealth Group
10.2016 - Current
- Review incoming appeal request from providers regarding denied claim involving OptumInsight denial reason codes via ICARE system
- Reopen cases for clinical review via Optum PICTS system
- Review claims in COSMOS/CPW claims platform
- Reprocess claims for payment that clinical overturned
- Write resolution letters on cases that clinical upheld denials
- Answer team member questions regarding a case.
- Completed documentation of final appeals or grievance determination using appropriate templates.
- Researched and resolved written complaints submitted by consumers and physicians or providers.
- Improved customer satisfaction by efficiently handling and resolving appeals in a timely manner.
- Conducted comprehensive reviews of claim denials, identifying errors or discrepancies that led to successful reversals on appeal.
Senior Appeals Representative Community & State Dual Special Needs Plan
UnitedHealth Group
01.2013 - 10.2016
- Review incoming appeal request from providers regarding underpayments or denied claims via the ETS system
- Follow the SOPs that pertain to provider status with plan and issue being appealed/disputed
- Routed cases to Internal Departments when needed
- Review claims in claims platforms - CSP Facet or COSMOS/CPW
- Learned Triage DDE system
- Learned Adjustments for CSP Facets and CPW
- Work OptumInsight Fraud and Abuse (FAB) cases with Optum Detect/PICTS system
- Kept track of cases to assure they were completed within compliance timeframe
- Wrote up resolution letter once decision received, assure that all required documentation is attached to case before closing case
- Assisted with running Daily reports when Supervisor was out
- Ran team huddles to review team numbers during Supervisor or SME absence
- Assisted team members with question on their cases or on what process to follow.
- Examined case to initiate clinical review.
- Managed sensitive client information with confidentiality and discretion, maintaining trust between customers and the company.
- Developed training materials for new hires, ensuring consistent quality standards across the team.
- Obtained additional documentation required for case review.
Senior Billing Representative
Ingenix/Caretracker
01.2008 - 01.2013
- Resolve open and denied medical claims for various specialties - Pediatrics, OB/GYN, Cardiology, and Ophthalmology with all major insurances carriers
- Monitor AR associates work load to assure they are working each client effectively and assist where needed
- Audit AR associates work monthly to assure they are following Standard Operating Procedures and review my findings with each associate
- Run reports on Dashboard weekly to check that each client account is being worked per contract agreement
- Train new hires on the day to day workflow, how to resolve denial by insurance carrier, and how to research for policies on the insurance carrier website
- Trained 30 new hires via Webex on the description of the denial and steps needs to resolve the denial
- Interim Account Manager - be the client liaison, run Month End Reports.
- Maintained strong relationships with clients through effective communication and excellent customer service, resulting in high client retention rates.
- Identified areas for improvement within current systems and processes, contributing valuable input towards continuous departmental progress.
- Provided support during financial audits by supplying necessary documentation and responding promptly to inquiries.
- Monitored account activity regularly for early detection of potential credit risks or collection issues.
- Resolve open and denied medical claims for assigned clients with Medicare Part B, Mass Health, and Blue Cross Blue Shield
- Provide management with policies on procedures for the effective management and handle on billing function
- Monitor outstanding balances and take appropriate action to ensure client's claims are paid
- Assisted team members with their denial batches when they are back logged
- Assist team members with claims related issues
- Participated in Daily calls with the Client.
- Reviewed and solved account and billing discrepancies.
- Trained new hires on company-specific billing software, policies, and procedures, promoting team cohesion and productivity.
- Identified, researched, and resolved billing variances to maintain system accuracy and currency.
- Enhanced overall departmental performance by proactively sharing best practices, tips, and lessons learned from daily billing activities with colleagues.
Lead Adjudicator
Pharmerica
01.2008
- Monitor all pharmacy claims for assigned groups
- Call Insurance carriers - Medicare D for override for change in orders or vacation override
- Spoke with Pharmacy staff regarding new patients and requested orders to be pulled from delivery
- Call Long Term facilities regarding denied claims for refill too soon or coverage issues
- Need to ask if facility would take responsible for the claim
- Assigned groups to staff members, ran end of day reports.
Billing Analyst
BROOKS/ECKERD PHARMACY
01.2006 - 01.2007
- Resolved open and denied claims for customers with Medicare Part B insurance coverage utilizing knowledge of Medicare formulary and policies
- Audited overpayments by Medicare to determine if money was due back to Medicare or to the customer to meet Federal Medicare compliance regulations
- Resolved system generated account mistakes by hand to reconcile actual payments to what the system showed as open claims
- Reconciled accounts worth approximately $200K in a span of one year
- Wrote a procedure to reduce Medicare rejects by approximately 20%
- Asked for and was granted the ability to access both the Brooks and Eckerd pharmacy systems for processing Medicare claims
- Reprocessed approximately 50 claims daily, which freed up Pharmacists time to work with customers and expedited payment from Medicare to Brooks Eckerd saving in the area of $3500/day
- Learned the complexities of the pharmacy systems quickly to process work efficiently
- Worked closely with billing vendors, ERX Network and Omnisys, Brooks Eckerd pharmacists and insurance carrier to resolve Medicare eligibility or claim processing issues.
Supervisor, Medicare Billing and Rejection
CVS PHARMACY, INC.
01.2002 - 01.2005
- Managed 11-20 Billing and Rejection Processors and a six person call-in help desk handling 100+ calls daily
- Interviewed, hired and trained new employees to be contributing members of the Medicare Part B team
- Coached associates to meet strict CVS employment policies
- Identified each associate's learning and motivational triggers and worked with their strengths to keep and improve their productivity, quality and career development
- Tracked each associates time worked and time off activities to ensure that information was accurately entered into the Kronos time and attendance system
- Collaborated with Programmer with ANSI 837, NCPDP 1.1 and 835 format to debug the programming for a new billing system
- Reviewed regularly the Durable Medical Equipment Regional Carriers (DMERC), National Drug Code (NDC) Crosswalk to HIPAA, Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) updates and changes to policies to ensure that CVS was following all current regulations
- Resolve Medicare rejected claims
- Managed the help desk such that staff resolved pharmacists' questions or issues in an average of three minutes
- Built relationships with DMERC personnel to expedite the resolution of large, complex rejections of claims.
Medicare Billing Analyst
CVS PHARMACY, INC.
01.2002 - 01.2003
- Processed payments for Medicare Part B claims
- Designed, implemented and maintained several Access databases to improve productivity and quality
- One database tracked incoming calls which resulted in issues resolved in the one day and identified trends in issues
- Another database held the provider numbers for various agencies to have a centralized bank of contact information
- Developed procedures and a database which helped associates find Medicare Part B payments and rejections so they could work them faster than the system output allowed
- Assisted colleagues with Microsoft Office usage and minor computer problems.
Third Party Collection Clerk
BROOKS MAXI DRUG, INC.
01.1995 - 01.2002
- Promoted to headquarters from a store
- Reconciled payments from insurance carriers and resolved carrier problems.
Customer Service Representative
BROOKS MAXI DRUG, INC.
01.1994 - 01.1995
- Provided customer service in the video rental department and handled front of store cashier role.
Education
A.S - Computer Information Systems in Programming
New England Institute of Technology
Warwick, RI05.2001
Certificate - Executive Assistant Program
Katherine Gibbs
Providence, RI05.1998
A.S. - General Business
Community College of Rhode Island
Warwick, RI05.1990
Skills
Business Process Management (BPM) systems
- ICARE - Compliance, Analytics, Resolution and Experience
- ETS - Escalation Tracking System
- DDE - Dual Data Entry
- ATS - Appeal Tracking System
- CPW - Claim Processor WorkStation
- CPA - Claim Processing Application
- ISET - Integrated Service Experience Tool
- COSMOS - Comprehensive Online Software for management and Operational Support
- CSP FACETS
- NICE - Claim Platform
- ORS - Online Routing System
- PICTS/Detect database
- MS Office
- Case Evaluation
- Teamwork and Collaboration
- Time Management
- Attention to Detail
- Multitasking
- Reliability
Certification
Certified Professional Coder (CPC)
Timeline
Senior Appeals Representative Medicare and Retirement
UnitedHealth Group
10.2016 - Current
Senior Appeals Representative Community & State Dual Special Needs Plan
UnitedHealth Group
01.2013 - 10.2016
Senior Billing Representative
Ingenix/Caretracker
01.2008 - 01.2013
Lead Adjudicator
Pharmerica
01.2008
Billing Analyst
BROOKS/ECKERD PHARMACY
01.2006 - 01.2007
Supervisor, Medicare Billing and Rejection
CVS PHARMACY, INC.
01.2002 - 01.2005
Medicare Billing Analyst
CVS PHARMACY, INC.
01.2002 - 01.2003
Third Party Collection Clerk
BROOKS MAXI DRUG, INC.
01.1995 - 01.2002
Customer Service Representative
BROOKS MAXI DRUG, INC.
01.1994 - 01.1995
Certificate - Executive Assistant Program
Katherine Gibbs
A.S. - General Business
Community College of Rhode Island
A.S - Computer Information Systems in Programming
New England Institute of Technology
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