RACHEL Castellez-DAVIDSON
Dover,NH
Summary
Ambitious Healthcare Revenue Case Manager & Clinical Appeals Specialist with 20 years of experience managing patients' medical insurance, clinical information, obtaining payment authorizations and scheduling & preparing treatments for customers. 200 Hour Registered (Trauma Sensitive Trauma Informed Yoga) Yoga Teacher with a passion for enriching other people's lives through their mental, physical, and holistic well-being. First-rate expert at customer communications, data compilation and organization. Diligent and meticulous professional commended for quickly and accurately learning new procedures and investigational proficiency. Expertise in high dollar revenue recovery, drafting clinical and policy letters, clinical appeals, medical policy/contracting, process improvements, and commitment to patients.
Overview
21
21
years of professional experience
Work History
Revenue Cycle Analyst
Natera
12.2022 - Current
- Personally created a new process of resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt resulting in a direct financial recoupment of over $4 million.
- Collaborated with other business analysts to streamline tasks and duties in effort to improve overall efficiency.
- Enrolled providers and Medicaid, Medicare and private insurance plans for 100 lab sites.
- Received and evaluated applications to look for missing and inaccurate information, teamed with multiple departments.
- Improved office efficiency by effectively managing internal communications and correspondence. Created and managed Smartsheets to better track and enhance enrollments.
- Reviewed tens of thousands of insurance and claims documents to verify required information and secure any missing data for settlements.
Provider Enrollment Credentialing Coordinator
HCA Physician Services Group
05.2022 - 12.2022
- Maintains and manages all credentialing and reappointments for all physicians and physician extenders.
- Completes initial credentialing/recredentialing applications on all physicians for local and outreach hospitals.
- Assists Payor Enrollment with provider credentialing, networking, prioauthorization and claim denials.
- Ensures all physicians' licensure, DEA, and clinical certifications are active and current.
- Maintains outbound/inbound communications amongst clinical, administration, and Board of Medicine.
- Responsible for entirety of Northeast Capital Market provider onboarding.
- Communicates effectively with staff members of operations, finance and clinical departments.
- Reviewed outstanding requests and redirected workloads to complete projects on time.
- Coordinated with contracting department to resolve payer issues.
- Checked documentation for accuracy and validity on updated systems.
Assistant Manager
Athleta
10.2021 - 05.2022
- Processed cashier transactions quickly and accurately, driving brand loyalty programs.
- Managed over 20 employees, managing store funds, problem solving sales, creating floorsets, designating and prioritizing duties.
- A leader in customer experience, leading the region in credit card and loyalty sales and programs, as such coaching Associates to do the same.
- Engaged, educated and befriended customers to deliver amazing shopping experience.
- Drove sales and service using suggestive selling techniques and observing non-verbal cues.
- Approached strangers and interacted in natural conversation with goal of developing brand loyalty.
Denials & Appeals Specialist
Prisma Health
02.2021 - 11.2021
- Implements best practice standards for billing resulting in substantial reduction of accounts receivable delays. Reviewed denied claims to determine cause and next steps.
- Successfully retained upwards of $500k amount of dollars per week through appeals.
- Overturned a number of out of network appeals.
- Reviewed and edited billing codes for inpatient and procedure charge accuracy.
- Reviews clinical medical records, identifying off-label diagnoses from clinical documentation creating clinical arguments for State Fair Hearings and other external appeals to support medical necessity for treatments.
- Creates and maintains data documentation and tracking for challenging cases and financial assistance accounts who do not qualify.
- Assists Clinical Case Managers in identifying patient encounters which will need to be appealed. This includes researching Payor policies and procedures, interpreting clinical documentation, creating and writing appeal letters, and initiating appeal through Payor.
- Work exclusively in Epic, proficient in navigating and utilizing the software program.
- Familiar with DDS, CMS Medicare & Medicaid systems, and many other Commercial Payor systems.
Clinical Appeals Specialist
Novocure
01.2016 - 09.2020
- Operates in Reimbursement Case Management team leadership role supporting Revenue Cycle Operations in appealing insurance denials from government and commercial carriers
- Collaborates with Health Policy on medical policies and payer contracts
- Reviews clinical medical records, identifying off-label diagnoses from clinical documentation creating clinical arguments for State Fair Hearings and other external appeals to support medical necessity for treatments
- Instructs and participates in multiple training sessions for other departments to further team collaboration and efficiency
- Assists in training new personnel and creates individual training plans
- Sole point of contact in Revenue Operations; managing patients waiting for insurance approvals prior to start of treatment
- Communicates directly with corporate executives submitting specific requests for employer benefit exceptions
- Facilitated two major commercial payers to adopt positive coverages leading to national contracts
- Creates and maintains data documentation and tracking for challenging cases and financial assistance accounts who do not qualify
Administrative Assistant - Case Management
Wentworth-Douglass Hospital
01.2013 - 10.2015
- Teamed up with managers to create specific patient monthly reports for executive review. Audited charts and reviewed clinical documents to verify accuracy.
- Communicated with supervisor regarding issues related to case management, resourcing, service collaboration and development of new resources.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Educated patients and answered questions about health condition, prognosis and treatment. Assisted with Notary duties of Advanced Living Wills.
- Updated patient charts using Sorian with data such as insurance and healthcare providers to keep records current and support accurate treatments.
Imaging Services/Other Positions Held
Wentworth-Douglass Hospital
12.2002 - 01.2013
- Imaging Services/Laboratory Department Senior Administrative Assistant - Other positions held.
- Worked directly under Directors for Imaging Services and Laboratory Services performing all administrative duties, including but not limited to Payroll, departmental equipment, orders, schedules, profit & loss reports, Press Ganey.
- Transcribed patient diagnostic information into radiology and hospital information systems.
- Complied with HIPAA and company regulations to maintain confidentiality regarding patient health data and medical records.
- Welcomed patients and tried to make procedures as pleasant as possible through discretion and personal support.
- Registered, scheduled, patients Imaging Services.
- Switchboard Operator 2002-2007
Education
200 Hour Registered Yoga Teacher Certification - Yoga Therapy And Teacher Training
Yoga And Ayurveda Center
New Jersey02.2021
Bachelor of Arts - Anthropology
University of New Hampshire
Durham, NH2008
Associate of Science - Applied Animal Science And Business
University Of New Hampshire
Durham, NH06.2007
Skills
- Case Management
- Revenue Cycle Management
- Clinical provider onboarding/licensing
- Epic/Sorian/Salesforce/SAP/CRM/Microsoft Suite/Google Office
- Brain Tumor & Mesothelioma Clinical Appeals Specialist
- Contracts & Policies/Commercial & Government Insurance Payors/Enrollment & Credentialing
- Customer service
- Leadership & Management
- Marketing strategies
- Patient advocacy
- Problem Solving & Research
- Clinical assessment
- Clinical team oversight
COMMUNITY INVOLVEMENT
- RYT200 (Trauma Informed Yoga) at 3 local studios - Teaching Yoga and Breathing techniques to those new to Yoga on a voluntary basis. Created a year long program teaching free Yoga to survivors of domestic violence, sexual assault, and stalking with a local shelter.
- Dover Mounted Police, Volunteer - Barn management, horse training & exercise, preparation & participation in police related events
- Yoga & Ayurveda Center - Yoga community involvement, including creating class plans and instructing via teleconference
- Board of Directors member of Chief Michael Maloney Memorial Fund from 2014-2016 - Assisting in managing a large Law Enforcement Charity
Timeline
Revenue Cycle Analyst
Natera
12.2022 - Current
Provider Enrollment Credentialing Coordinator
HCA Physician Services Group
05.2022 - 12.2022
Assistant Manager
Athleta
10.2021 - 05.2022
Denials & Appeals Specialist
Prisma Health
02.2021 - 11.2021
Clinical Appeals Specialist
Novocure
01.2016 - 09.2020
Administrative Assistant - Case Management
Wentworth-Douglass Hospital
01.2013 - 10.2015
Imaging Services/Other Positions Held
Wentworth-Douglass Hospital
12.2002 - 01.2013
200 Hour Registered Yoga Teacher Certification - Yoga Therapy And Teacher Training
Yoga And Ayurveda Center
Bachelor of Arts - Anthropology
University of New Hampshire
Associate of Science - Applied Animal Science And Business
University Of New Hampshire
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