Monica Simmons
Jacksonville,FL
Summary
Detail-focused Quality Auditor known for productivity and efficiency in task completion. Specialize in process optimization, compliance monitoring, and risk management, bringing valuable insights into operational improvements. Excel in communication, problem-solving, and adaptability, ensuring seamless coordination across teams to maintain high standards of quality control.
Overview
23
23
years of professional experience
Work History
Quality Auditor
GuideWell Source
Jacksonville, FL
03.2006 - 10.2024
- Provided customer service by doing provider callbacks
- Gathering, analyzing and/or verify information needed to process claims and assisted as a Subject Matter Expert in the different work areas and types
- Doing side-by-side training and assisting in training class with new examiners
- Participate in Claims new hire interview panels
- Adjudicating, Reviewing, researching, analyzing, verifying Diagnostic and HCPC codes ICD-9
- Auditing the on Part A and B examiners work and answering questions on work types.
- Such as 138/Utilization Audits (Pricing), MSP/ECRS Utilization along will all EMC work-types paper and non-paper
- Submit submission of PPR’s on the changes that need to be made in the Stellant Manuel Program/Work Instructions
- Working along with the Operations Department to change and approve changes made in the Work Instructions,
- Submit MSP CWF and ECRS Request
- Operating MCS, HIMR, ECRS, FISS, and all Microsoft systems
- Appeals, Adjustment, Ordering, Inspecting and Auditing the monthly Claims MSN CCEP report
- Processed Duplicate, Utilization, Pricing Audits and MSP claims in the MCS system
- Processed Medicare Part B and A claims using a PC and/or CRT with ECRS, HCPC, ICD-9 codes, EMC and OCR
- Conducted internal audits to ensure compliance with quality standards.
- Verified accuracy of inspection records and updated them as required.
Claims Examiner
First Coast Service Options
Jacksonville, FL
10.2001 - 03.2006
- Reviewed medical claims dispatched directly from the doctor’s office
- Provided customer service by; verifying medical information to ensure claims were processed correctly
- Processed 1500 and 1400 UB forms and corrected 45c and 600 claims batches, including attachments
- Processed Medicare Part B claims using a PC and/or CRT with ICD-9 codes, EMC and OCR
- Also input patient information and EMC on W03s, B05's, and R04’s via the OCR application
- Processed Duplicate, Utilization, Pricing Audits and MSP claims in the MCS system
- Along with processing the Z99 delete process
- Reviewed and evaluated insurance claims to determine coverage and validity.
- Researched complex billing errors that required an in-depth review of all available documentation before resolution could be reached.
Education
High School -
Andrew Jackson High School
01.1989
Health Care Management and Medical Coding
Florida State College at Jacksonville
FLSkills
- 35 years of Customer Service experience
- 35 years of Data Entry,
- 23 years of Medical Claims Experience
- 15 years of Quality Auditing experience
- 10 years of Claims processing experience
- Dedicated team player
- Working knowledge of MSP, MCS, HIMR, FISS, EUA, HCPC, ICD-9 and 1500 claim form
- Windows, Microsoft Office, Word, Excel, PowerPoint and Teams
- Ten Key,45wpm,
- Documentation management
- ISO 9001
- Customer focus
Timeline
Quality Auditor
GuideWell Source
03.2006 - 10.2024
Claims Examiner
First Coast Service Options
10.2001 - 03.2006
High School -
Andrew Jackson High School
Health Care Management and Medical Coding
Florida State College at Jacksonville
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