Misty Womack
Manager Medical Claim Adjudication
Dayton,US
Summary
Manager Medical Claim Analyst/Adjudicator with extensive 28-year history in medical claim processing. Working denial/audits Pharmacy LTC, Managed Care carve out claims. DME supply claims across multiple states, obtaining prior authorizations, and speaking to clinical staff to ensure we were supplying correct orders ahead of admissions. Expert in leveraging data analytics for process enhancements and supporting rigorous compliance with Medicare and Medicaid regulations. Proven leader in developing training programs that elevate team performance and perfect claims processes. Created onboarding materials for DME training/Medicare Part B training. Collaborated with new associates through training, supplying knowledge transfer and guidance.
Overview
12
12
years of professional experience
Work History
Supervisor Medicare Part B/Medicaid Adjudicator
CVS/Omnicare
Dayton, US
09.2012 - Current
- Managed billing for Medicaid DME supply claims for multiple states
- Utilized external Medicaid portals for claims submission
- Specialized in Long Term Care Billing
- Utilize data analytics tools to show trends and patterns in Medicare Part B/Medicaid claims processing and supply recommendations for process improvements to enhance efficiency and accuracy
- Develop and support relationships with Medicaid and Medicare agencies to stay updated on changes in regulations and policies, ensuring compliance and maximizing reimbursement opportunities for CVS/Omnicare
- Implement training programs to educate team members on the latest updates and changes in Medicare Part B and Medicaid regulations, ensuring compliance and efficiency in claims processing
- Lead cross-functional teams to streamline the Medicare Part B/Medicaid claims adjudication process, ensuring prompt and correct processing while maximizing reimbursement opportunities for CVS/Omnicare
- Collaborate with cross-functional teams to find opportunities for process improvement and streamline communication between departments to enhance overall efficiency in Medicare Part B and Medicaid claims adjudication for CVS/Omnicare
- Collaborate with the IT department to find and implement technological solutions that streamline Medicare Part B/Medicaid claims adjudication processes, increasing efficiency and accuracy for CVS/Omnicare
- Learned and managed third party hard copy billing for paper claim billing
- Negotiating claim window reopening for resubmission for maximum reimbursement
- Develop and implement quality assurance processes to ensure that Medicare Part B and Medicaid claims are accurately processed and follow all regulatory requirements, reducing errors and maximizing reimbursement opportunities for CVS/Omnicare
- Develop and implement strategies to proactively find and address potential compliance issues in Medicare Part B/Medicaid claims processing, ensuring adherence to regulations and minimizing risks for CVS/Omnicare
- Analyze and assess the impact of upcoming changes in Medicaid and Medicare regulations on claims processing, and supply recommendations to proactively adjust processes and strategies to keep compliance and maximize reimbursement opportunities for CVS/Omnicare
- Lead the implementation of a continuous improvement culture within the Medicare Part B/Medicaid adjudication team at CVS/Omnicare, encouraging team members to actively take part in showing inefficiencies, proposing solutions, and implementing process enhancements to perfect claims processing efficiency and accuracy
- Find and implement opportunities to enhance cross-departmental collaboration and communication, fostering a more efficient and cohesive approach to Medicare Part B/Medicaid claims adjudication for CVS/Omnicare
- Establish and keep relationships with key external stakeholders, such as healthcare providers and State Medicaid agencies, to foster collaboration and ensure seamless claims processing for CVS/Omnicare, ultimately maximizing reimbursement opportunities and maintaining compliance with Medicare Part B/Medicaid regulations
- Supply strategic guidance and recommendations on leveraging data analytics and innovative technology solutions to perfect Medicare Part B/ Medicaid claims adjudication processes, enhancing efficiency, accuracy, and reimbursement opportunities for CVS/Omnicare
- Analyzed billing data to reduce claim discrepancies by 15%, ensuring higher compliance
- Expedited claim adjustments, reducing processing time by 20% through effective negotiations
- Initiated a predictive analytics model to forecast claim issues, enhancing preemptive actions
- Analyzed multi-state Medicaid claim patterns to enhance CVS/Omnicare's billing strategies
- Pioneered tech integrations to boost accuracy in Medicare Part B/Medicaid claims at CVS/Omnicare
- Spearheaded a quality assurance initiative that significantly reduced billing errors
Respiratory Therapist
Dayton, US
01.1996
- Conducted patient assessments and recommended treatments for home care, ensuring smooth transitions
- Coordinated with healthcare teams to supply necessary equipment, enhancing patient care quality
- Visited long-term care facilities to evaluate and adjust resident therapies, improving outcomes
- Transitioned to billing, streamlining processes, and ensuring accurate documentation
- Eager to master recent technologies and contribute positively to team goals
- Optimized patient care protocols in diverse settings, enhancing treatment efficacy
- Analyzed patient data to refine care plans, reducing recovery times
- Supported team adaptation to new healthcare regulations, ensuring compliance
Education
Associate degree - Business Management
Sinclair Community College
Associate degree - Science/Advanced Respiratory Therapy Degree
Mountain Empire Community College
Skills
- Staff Management
- Process Improvement
- Strategic Planning
- Expectation setting
- Priority management
- Complex Problem-Solving
- Staff Development
- Process Monitoring and Improvement
- Employee Motivation
- Staff Discipline
- Processes and procedures
- Goal-Oriented
- Training and mentoring
- Policy Enforcement
- Business Administration
- Business Development
- Department organization
- Teamwork and Collaboration
- Multitasking Abilities
- Attention to Detail
- Time Management
- Excellent Communication
- Decision-Making
- Adaptability and Flexibility
- Effective Communication
- Organizational Skills
- Analytical Thinking
- Team building
- Active Listening
- Professionalism
- Interpersonal Skills
- Self Motivation
- Written Communication
- Improvement plan knowledge
- Idea Development and Brainstorming
- Conflict Resolution
- Quality Assurance
- Interpersonal Communication
- Time management abilities
- Professional Demeanor
- Team Collaboration
- Continuous Improvement
- Goal Setting
Work Preference
Work Type
Full TimeLocation Preference
RemoteTimeline
Supervisor Medicare Part B/Medicaid Adjudicator
CVS/Omnicare
09.2012 - Current
Respiratory Therapist
01.1996
Associate degree - Business Management
Sinclair Community College
Associate degree - Science/Advanced Respiratory Therapy Degree
Mountain Empire Community College
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