Nina Pritchett
Union City,GA
Summary
Polished and hardworking performer with 15+ years in the healthcare industry. Reliable Medical Professional, with insurance ,coding and medical terminology knowledge. Team-oriented person with great decision-making skills.
Overview
17
17
years of professional experience
Work History
Medical Biller
Peachtree Cardiology
01.2023 - Current
- Precisely evaluated and verified benefits and eligibility.
- Ensured timely submission of claims to various insurance carriers, resulting in prompt payment for services rendered.
- Examined patients' insurance coverage, deductibles, insurance carrier payments and remaining balances not covered under policies when applicable.
- Analyzed complex Explanation of Benefits forms to verify correct billing of insurance carriers.
- Efficiently processed refunds or adjustments for patients when necessary, ensuring accuracy and compliance with company policies.
- Monitored changes in payer requirements, adjusting billing practices accordingly to minimize disruptions in the revenue cycle.
- Communicated with patients for unpaid claims for HMO, PPO and private accounts and delivered friendly follow-up calls for proper payments to contracts.
SENIOR GRIEVANCE & APPEALS COORDINATOR
PEACH STATE HEALTH PLAN-CENTENE CORPORATION
01.2019 - 02.2021
- Served as subject matter expert for the member Grievance and Appeals department
- Maintained 99% accuracy on quality audits as well as 100% compliance for 2020 calendar year
- Resolved an average of 50+ appeals/ 30 grievances per month
- Conducted appropriate review of claims and prior claim payment history; submitted for reprocessing when applicable
- Resolved complaints submitted by the Office of the Insurance Commissioner, Corporate Office and Congressional complaints within the required 24–72-hour time frame
- Ensured to input all appeal/grievances into database daily and tracked cases per departmental policies
- Adhered to strict guidelines set by The Centers of Medicare and Medicaid services (CMS), The National Committee for Quality Assurance (NCQA), and the health plan
- Responsible for training incoming coordinators and performed side by side training
- Handled monthly/quarterly reporting and analysis for quality improvement and departmental and state audit purposes
- Redesigned tracking templates and assisted with updating Appeal and Grievance letters
- Volunteered for and assigned special projects from the Senior Leadership team.
GRIEVANCE & APPEALS COORDINATOR
PEACH STATE HEALTH PLAN
02.2015 - 01.2019
- Triaged, assigned and processed expedited claim/medical necessity appeals and grievances (Medicaid and Exchange)
- Investigated and resolved 60+ appeals (standard/expedited) and grievances and correspondence within regulatory guidelines per month
- Composed 50-100 written denial notifications, assisted with training new coordinators and presented and educated other departments on policies and procedures
- Worked with providers, members, Medical Directors, delegated vendors to improve processes and ensured all concerns were rectified
- Contributed to 60% reduction in appeal turn-around time and a 90% increase in monthly closed cases rate, which enhanced productivity and member and provider service
- Achieved 'key-contributor' bonus award for 2018 due to outstanding performance and exceeding departmental goals.
APPEALS & DENIAL COORDINATOR
PEACH STATE HEALTH PLAN
03.2013 - 02.2015
- Drafted average of 100 written denial notifications that ensured communication compliance within CMS and NCQA guidelines
- Processed 30+ appeals per month, which included gathering medical records/policies/consent and provider/member outreach if applicable
- Developed and maintained great working relationships throughout health plan and with customers
- Received and initiated provider requests for peer review with Medical Directors
- Provided responses to provider and member inquiries requested from customer service agents.
REFERRAL SPECIALIST
PEACH STATE HEALTH PLAN
11.2010 - 03.2013
- Approved 50+ prior authorizations daily within, corresponding letters faxed to providers, maintained a phone service level of 95% or better
- Verified member eligibility via MMIS web portal, determined provider and facility contract status
- Successfully processed urgent time-sensitive and specialty prior authorization requests within appropriate timeframe
- Achieved Notable Contribution Award due to high productivity and excellent customer service.
LEAD FRONT OFFICE MEDICAL ASSISTANT
METROPOLITAN ATLANTA CARDIOLOGY CONSULTANTS
09.2007 - 09.2009
- Promptly checked-in patients within required 15-minute window, assisted with completion of forms and provided detailed insurance benefit and plan information
- Insurance verification for all physicians, obtained referrals and pre-certifications for a variety of cardiac testing and procedures
- Physician consults, answered roll-over and backline phone calls
- Utilized EMR, trained new employees, provided guidance and leadership to colleagues, and served as a mentor to their day-to-day responsibilities.
Education
MEDICAL INSURANCE BILLING AND CODING CERTIFICATE -
GEORGIA MEDICAL INSTITUTE
Jonesboro, GA01.2004
HIGH SCHOOL DIPLOMA -
ANN ARBOR PIONEER HIGH
Ann Arbor, MI06.1998
Skills
- Microsoft Office
- Insurance Claims
- Medical Billing
- Denial Management
- Electronic Claims
- Insurance Verification
- CPT/ ICD-10 Knowledge
- Billing and Collection Procedures
- Data Entry
- Payment posting
- Medical terminology expert
- Medical coding knowledge
- Insurance Billing
Timeline
Medical Biller
Peachtree Cardiology
01.2023 - Current
SENIOR GRIEVANCE & APPEALS COORDINATOR
PEACH STATE HEALTH PLAN-CENTENE CORPORATION
01.2019 - 02.2021
GRIEVANCE & APPEALS COORDINATOR
PEACH STATE HEALTH PLAN
02.2015 - 01.2019
APPEALS & DENIAL COORDINATOR
PEACH STATE HEALTH PLAN
03.2013 - 02.2015
REFERRAL SPECIALIST
PEACH STATE HEALTH PLAN
11.2010 - 03.2013
LEAD FRONT OFFICE MEDICAL ASSISTANT
METROPOLITAN ATLANTA CARDIOLOGY CONSULTANTS
09.2007 - 09.2009
MEDICAL INSURANCE BILLING AND CODING CERTIFICATE -
GEORGIA MEDICAL INSTITUTE
HIGH SCHOOL DIPLOMA -
ANN ARBOR PIONEER HIGH
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