Patricia Jenkins- Crenshaw
Pinson
Summary
Results-driven Medical Billing Specialist with a strong background in, several aspects of medical billing, claims auditing, provider and member service representative, claims denial resolutions analyst, and medical grievance and appeals experience, with over 35 years’ experience, seeking a challenging position within a stable company, where my experiences and abilities to interact with a broad base of clientele both internal and external, and promote an opportunity to grow and achieve maximum successes for the company.
Overview
6
6
years of professional experience
Work History
Catalyst Solutions(Contractor) Health First, Inc.
09.2024 - 01.2025
- Reviewed and researched Medicaid, Medicare claims to determine possible payment accuracy.
- Determined accurate payment criteria for clearing pending claims based on defined Policy and Procedure, while examining all error codes, warning messages and edits for correct processing.
- Processed medical and/or hospital claims in accordance with the Plan rules, including in- and out-of-network claims, complex claims and adjustments.
- Maintained productivity goals, quality standards and aging timeframes.
- When necessary, ensured proper authorization and referrals were obtained as required by the plan for processing claim prior to completion of payment.
- Met all established performance standards, including claims processing standards for quantity, accuracy (coding and financial) and turnaround time.
Claims Analyst Team Lead
Health First, Inc.
04.2022 - 08.2022
- Assist by supporting the Supervisor in daily operations and processes of medical claims within the department.
- Accountable for the daily, weekly, and monthly activities of a staff of 10-15 claims processing associates remotely, while assuring that production minimum of 17-20 claims per hour was met for each processor.
- Created a high-performing, results-oriented staff through candidate selection, on-boarding, ongoing development, and training, managing individual performance with regular coaching focused on behavior and technical skill sets.
- Identify and notify the supervisor of potential escalated issues or system related concerns.
- Provide support to the team members and serve as a resource answering questions in addition to serving as subject matter expert and back-up to the production team as needed.
- Supported the quality audit review and rebuttal process with additional training and one on ones with Team members.
- Reviewed the team's work performance to ensure accuracy and efficiency on a daily/weekly basis.
- Implemented a daily operations governance process to analyze, prioritize and deliver daily, weekly, monthly targets, through reports to the client.
- Remote- Short Term Contractor
- Claims Analyst Team Lead- Jacobson Solutions
Provider Service Representative
WPS Health Solutions TRICARE Humana Military Healthcare.
11.2021 - 04.2022
- Took inbound calls to address providers’ needs which may include complex financial recovery, answer questions, and resolving issues pertaining to their claims and enrollment resolutions.
- Focused on resolving issues on the first call, navigate through the appropriate computer system(s) to identify the status of the issue and provide appropriate response to caller.
- Delivered all information and questions in a positive, conversational, and compassionate manner to facilitate developing a relationship with the provider community, while providing the best customer service experience possible.
- Completed documentation necessary to track provider issues and facilitate the reporting of overall trend.
- Educated participating and non-participating providers regarding policies and procedures related to referrals and claims submission, web-site usage, EDI solutions and related TRICARE topics.
- Initiated re-certifications and revalidation to maintain provider credentials and enrollment activ
- Remote Contractor Jacobson Solutions (work from home)
Customer Service Representative Providers Services
Monroe Health Plan Buffalo, NY (contractor)
07.2019 - 01.2020
- Answer 100 + incoming phone calls from health care providers, hospitals and clinics to identify the type of assistance needed, such as benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs), enrollment of new providers.
- Focus on resolving issues on the first call, navigate through the appropriate computer system(s) to identify the status of the issue and provide appropriate response to caller.
- Delivered all information and questions in a positive, conversational and compassionate manner to facilitate developing a relationship with the provider community, while providing the best customer service experience possible.
- Completed documentation necessary to track provider issues and facilitate the reporting of overall trend.
- Provided oversight on inquiries, appeals referrals, authorizations and claims issues and followed up with providers to ensure problems have been resolved.
- Met performance goals established for their position in the areas of efficiency, call quality, provider, and member satisfaction first call resolution.
- Research and resolve issues related to the authorization process, including but not limited to gaps in authorizations, authorizations that need corrections as they arise.
- Completed timely and thorough investigation and processing of all grievances and appeals submitted by providers and subcontractors, which included clinical, non-clinical medical necessity claims appeals and grievances, ambulance claims appeals and grievances for New York State Medicaid Managed Care Program.
- Remote Contractor (work form- home)
- New York Medicaid Managed Care and Affordable Care Act Programs
Provider Dispute Analyst
Blue Cross and Blue Shield Texas, Richardson, TX
09.2018 - 06.2019
- Analyzed and resolved various denial trends for complex claims issues and payer behavior using company's billing system, payor portals, calling the provider, and Explanation of Payor(EOP) review.
- Maintain, tracked, and prioritized assigned caseload through Facet 5.0, ensuring timely completion by creating and maintaining spreadsheet.
- Reviewed and evaluate contract terms, interpretation and compile necessary supporting documentation for the resolution of a provider disputed claim.
- Documented faxed medical records reviewed with notes of recommended changes and education opportunities, while discussing these coding and documentation opportunities with appropriate personnel to ensure complete and accurate coding.
- Researched and reviewed both claims’ data and medical chart information to support Quality (HEDIS) and Risk (Medicare HCC and HHS HCC) initiatives.
- Process.
- Properly distinguish between a provider dispute and a provider appeal and generate and/or determined appropriate action steps for escalated provider disputes from Correspondence, Provider Research Team (PRT), Claims, and all other entities involved.
- Perform other duties as assigned.
- Remote Contractor (work from home)
- Medicare Advantage and Medicaid Managed Care Plans
Education
Penn Foster-Online - Medical Billing and Coding
01.2020
Bachelor of Fine Arts - Voice as a performance
Virginia Union University
01.1979
Skills
- Microsoft Office Suites, Data Entry, Word, Excel Spreadsheets, Access, Outlook, PowerPoint, and Viso Flowcharting
- ClaimLogic, Gateway EDI, Emdeon, Medicaid Claims Solutions, Logik Healthcare Recovery, Smart Data Solutions Quick Claims, EHS Success, On-Board powered through FACETS
KNOWLEDGE:
Expert knowledge of ICD10, CPT4, HCPCS I, II, III, UB04, HCFA1500, in depth knowledge of 5010 HIPAA transaction sets including 837,834,276, 277, 270, 271, reimbursement, cash posting, account receivables, insurance follow-up, electronic billing, appeals, grievances, patient eligibility, provider enrollment and credentialing, government and non-government healthcare policies and procedures, Center for Medicare/Medicaid (CMS). An understanding of patient confidentiality HIPAA, PHI, PPI, and Compliance, along with HEDIS and NCQA requirements and guidelines which include HEDIS and state-mandated quality metrics specification, abstraction, data entry, auditing, and clinical chart review for Medicaid and Medicare providers. Medicare, Medicare Advantage, Medicaid, Medicaid Managed Care, Third Party Payor, ASO-Self Funded plans, HMO’s, PPO, TRICARE Prime, Select and TRICARE for Life, BlueCross and Blue Shield companies and affiliates. Knowledge of The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and Coding updates to the ICD-10-CM for DSM5 effective 10/1/2018, Behavioral Health Both Inpatient and Outpatient. Provider claims dispute resolutions and research. Dental, Vision and Durable Medical Equipment (DME) coding. CDPT 2019-2021 for Dental Coding, medical terminology, anatomy, and physiology. Working experience with 855A Applications, 855B Applications, PECOS Provider Enrollment and Medicaid/Medicaid Advantage provider enrollment verification systems. Excellent root cause analysis skills, experience working in overpayment remediation of healthcare insurance claims
Timeline
Catalyst Solutions(Contractor) Health First, Inc.
09.2024 - 01.2025
Claims Analyst Team Lead
Health First, Inc.
04.2022 - 08.2022
Provider Service Representative
WPS Health Solutions TRICARE Humana Military Healthcare.
11.2021 - 04.2022
Customer Service Representative Providers Services
Monroe Health Plan Buffalo, NY (contractor)
07.2019 - 01.2020
Provider Dispute Analyst
Blue Cross and Blue Shield Texas, Richardson, TX
09.2018 - 06.2019
Bachelor of Fine Arts - Voice as a performance
Virginia Union University