ROWNEA CATES
Bogalusa,LA
Summary
Medical Claims professional with strong experience in claims research, medical bill review, reimbursement, PIP Medical/Pay Claims, insurance coverage and eligibility, payment processing, claim denials, appeals, and payment discrepancies. Skilled in reviewing medical documentation, EOBs, CPT/HCPCS, ICD-9/ICD-10, and reimbursement information to support accurate claim decisions and timely resolution. Experienced working with providers, payers, members, and attorneys while managing high-volume claims and multiple systems.
Overview
1
1
Certification
13
13
years of professional experience
Work History
Claims / Billing Analyst
Molina Healthcare
Long Beach, CA
01.2023 - Current
- Research, process, and resolve healthcare claims while navigating multiple computer systems and platforms to ensure claims are accurate, complete, and processed according to member benefit plans, company policies, regulations, and applicable laws. Review claims for coverage, eligibility, benefit limitations, reimbursement requirements, pricing, coding, modifiers, and supporting documentation to support appropriate payment or claim disposition. Verify insurance eligibility, effective dates, and coverage for HMO, PPO, POS, Blue Cross/Blue Shield, Medicaid, Medicare, Marketplace, and commercial plans. Review and interpret EOBs, payment information, CPT, HCPCS, revenue codes, modifiers, medical terminology, and billing documentation to identify discrepancies and support appropriate claim resolution.
- Appeal denied claims by researching claim history, benefits, documentation, coding, and payer requirements and submitting necessary information for reconsideration. Identify billing errors, payment discrepancies, coordination-of-benefits issues, and missing or inaccurate information and take corrective action.
- Contact patients and members to obtain or update insurance information and resolve coordination-of-benefits issues while maintaining confidentiality of sensitive claims records and submit accurate and timely billing, claim, and reimbursement information to insurance carriers and other appropriate parties. Post insurance payments and account adjustments according to payer payments and EOBs.
- Communicate with healthcare providers, attorneys, insurance representatives, patients, and internal departments to resolve disputed or contested claim amounts. Negotiate with healthcare providers, attorneys, and other parties, when applicable, to reach mutually beneficial resolutions regarding contested claim amounts.
- Maintain current knowledge of medical billing, coding, insurance benefits, reimbursement processes, and related requirements. Work independently while managing multiple priorities, maintaining accuracy, productivity, quality, and established performance expectations. Utilize EPIC, Encoded, and other systems to research claim information, document activity, process transactions, and maintain accurate records.
Reimbursement Specialist
Our Lady of the Angels Hospital
09.2021 - 12.2023
- Researched and processed medical reimbursement information using multiple computer systems and platforms, ensuring information was accurate, complete, and compliant with policies, regulations, and applicable laws and Reviewed claims, billing records, and supporting documentation to identify missing information, billing errors, improper payments, claim denials, underpayments, and other discrepancies, rectified claim denials and underpaid claims through corrected claims, appeals, payer follow-up, and detailed research to support appropriate resolution.
- Researched insurance coverage, payer requirements, medical necessity, reimbursement guidelines, and accurate pricing. Identified root causes and trends related to claim denials, billing discrepancies, and reimbursement issues and collaborated with Revenue Operations teams.
- Secured prior authorizations and ensured required documentation was prepared and submitted according to payer requirements, while communicating with payors regarding claims, eligibility, authorizations, required documentation, and reimbursement requirements. Monitored eligibility and changes that could affect reimbursement and case-mix adjustments.
- Provided front-line problem resolution and customer service to patients, members, providers, and internal departments and worked independently while managing multiple priorities and maintaining accurate documentation, confidentiality, and deadlines.
Intake Coordinator / Call Center Lead/Supervisor
University of Chicago Medical Center
Chicago, IL
05.2013 - 08.2021
- Managed patient registration and discharge processes and provided high-level customer service in a multidisciplinary clinical environment. Reviewed patient accounts and billing information for accuracy, identified discrepancies, processed payments, generated invoices, tracked payments, and resolved billing issues, contact insurance companies for medical review to benefit information and resolve coverage, eligibility, authorization. Verified insurance eligibility and benefits, including deductibles, copayments, coinsurance, out-of-pocket maximums, accumulators, authorization requirements, referrals, approved inpatient days, and payer billing information.
- Initiated, validated, and monitored authorizations, notifications, pre-certifications, and referrals, following up on pending items through resolution. Researched complex insurance and billing issues and collaborated with physicians, financial counselors, patients, and insurance representatives to determine appropriate next steps.
- Maintained strict confidentiality of protected health information and followed HIPAA and organizational requirements, knowledge of major medical insurance plans, medical terminology, and ICD-9/ICD-10 codes to troubleshoot coverage, billing, and patient account issues, monitor KPIs, productivity, quality metrics, and performance reports to identify process improvement opportunities and performed reviews, prepared monthly and quarterly performance reports, and communicated staffing and operational needs to upper management.
- Served as a liaison between patients, medical staff, insurance companies, and internal departments to facilitate timely and accurate communication. Supervised and cross-trained call center staff on multiple software systems, workflows, insurance processes, and customer service procedures.
Education
Illinois School of Health Careers
10-2005
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Mary Grand High School
Skills
- Medical Claims Research & Processing/ Medical Bill & Payment Review
- PIP / Medical Payments Transferable Skills
- Claims Denials & Appeals, Insurance Coverage , Eligibility
- Benefit Plan Interpretation
- Payment Discrepancy Resolution
- EOB & Reimbursement Review
- CPT / HCPCS / ICD-9 / ICD-10/ Medical Terminology
- Medical Terminology
Certification
Certified Medical Assistant (CMA), CPR Certified
Personal Information
Title: PIP Medical / Pay Claims Associate – National General
Timeline
Claims / Billing Analyst
Molina Healthcare
01.2023 - Current
Reimbursement Specialist
Our Lady of the Angels Hospital
09.2021 - 12.2023
Intake Coordinator / Call Center Lead/Supervisor
University of Chicago Medical Center
05.2013 - 08.2021
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Mary Grand High School
Illinois School of Health Careers