Shannel Trambley

• File insurance claims to clearinghouse or individual insurance companies electronically or via paper CMS-1500/UB-04 forms.
• Answer patient questions on patient responsible portions, copays, deductibles, write-off's, etc.
• Resoles patient complaints or explains why certain services are not covered.
• Follows up with insurance company on unpaid or rejected claims and discrepancies. Resolves issue and re-submits claims.
• Prepares patient statements for charges not covered by insurance. Ensures statements are electronically submitted and mailed on a regular basis.
• Preform "soft" collections for patient past due accounts. This may include contacting and notifying patients via phone or mail.
• Prepares and submits secondary claims.
• Verifies patient benefits eligibility and coverage.
• Ability to look up ICD 10 diagnosis and CPT treatment codes from online services or using traditional coding references.
• Understands and maintain HIPPA Compliance Standards relative to the PWHC and all other governing agency regulations.
• Prepares weekly reports on unlocked progress notes. Send reports to CEO and individual providers.
• Performed routine closings, maintained clean, accurate and accessible records and kept close eye on transaction updates throughout each quarter.
• Prepares and submits all monthly closing reports.
• Prepares monthly write-off reports. Presents report to board of directors.
• Review patient accounts for credit balances.
• Reviewed billing problems, researched issues and resolved concerns.
• Prepares reports and creates invoice for DWI program. Submit monthly invoice to County Manager for payment.

• Maintenance of all provider records within the health plan system(s). Includes : setup of demographic and specialty information, panel information, line of business and fee schedules as instructed.
• Demonstrated knowledge of HIPPA Privacy and Security Regulations by appropriately handling patient information.
• Manages and maintains multiple client's.
• Review and correct vendor/provider errors in applicable systems.
• Review and create fee schedules for LOA's and SCA's.
• Review and update fee schedules when W9's are received, remove auto denial and forward files to client's specific folder.
• Manages and configures contract reimbursement methodologies within specified timeframes into claims payment system.
• Tests and audits claims payment accuracy against contact information loaded into claims payment system.
• Completes assigned claims in processing status code report in a timely and accurate manor.
• Assists in configuration issues and loading of provider information.
• Partners with other departments to ensure appropriate data is collected and maintained.
• Interprets and configures contract terms and claims coding in a risk based environment.
• Ensured all providers are updated accurately and timely to meet compliance adherence thresholds.
• Acts as a resource to other internal departments on contract issues.
• Exceeds departmental timeframes and quality metrics on a consistent basis.
• Takes ownership of the work process, seeks ways to improve job and process efficiency and makes appropriate suggestions and solutions to management.
• Maintains records of provider credentials, ensuring compliance.
• Maintained strict confidentiality with all personal data as per company guidelines.
• Examines claims for adjustments and appeals.

• Resolves medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.
• Ensures legal compliance by following company policies, procedures, and guidelines as well as state and federal insurance regulations.
• Remains up to date with all insurance requirements.
• Accurately obtained provider and member information.
• Examined diagnosis codes for accuracy, completeness, specificity, and appropriateness according to services rendered.
• Interpreted medical reports containing ICD-9, ICD-10, CPT and HCPCS codes.
• Evaluated accuracy of provider charges including dates of service, procedures, level of care, locations, diagnosis, patient identification and provider signature.
• Verify prior authorizations.
• Address and resolve new or unusual claim errors.
• Use appropriate documentation and reference materials to process claims accurately and efficiently.
• Worked closely with other departments on special projects.
• Maintains quality costumer services by following customer services practices.
• Documents medical claims actions by completing forms, reports, logs, and records.
• Demonstrated knowledge of HIPPA Privacy and Security Regulations by appropriately handling patient information.
• Worked closely with supervisor to transition into the primary processor for FRA.
• Worked with supervisors and team members to understand inventory needs and bring levels within desired goals.
• Evaluated all evidence with the ultimate goal of creating positive outcomes for client's claims.
• Championed claims process by providing expert knowledge and building positive, trusting relationship to support clients during challenging times.
• Examines claims for adjustments and appeals.
• Supported FRA and other groups with special projects and additional job duties.
• Prepares for weekly pre-checks by making sure all priority providers, pend reports, pre-ckeck rework, claims tracker, P2P payments, PSR reports, emails and CareKinesis claims are processed and ready for pre-check to be ran.
• Engages directly with Clients, as needed, for Claims related inquiries and questions.

• Accurately process all insurance claims for all payers including Government payers.
• Analyze and resolve all billing errors to ensure claims are filed accurately within the payer’s filing limits and regulations.
• Adheres to regulatory rules and payer contracts mandated by CMS, state, and federal regulations.
• Works closely with cash team to resolve unapplied cash, credit balances and other posting issues.
• Follow-up on balances due from insurance.
• Responsible for submission of all electronic claims.
• Submits paper claims to non-electronic carriers with all required documentation attached.
• Verify benefit eligibility and coverage.
• Calculate, prepare, and issue bills, invoices, account statements according to established procedures.
• Analyze and process late charges.
• Gathering Itemized Statements and UB’s for nurse auditors.
• Compiling PDF files containing UB’s, itemized statements and patient medical records for other departments.
• Assisting with special projects and meeting curtail deadlines.
• Assisting and researching questions to solve unusual claim errors with team members.
• Accepting additional workload when other colleagues are absent.
• Assisting with training new hires on systems, billing formats and workflow.

• Demonstrated knowledge of HIPPA Privacy and Security Regulations by appropriately handling patient information.
• Strictly followed all federal and state guidelines.
• Remained up-to-date with all insurance requirements.
• Verify member eligibility for date of service.
• Accurately obtained provider and member information.
• Examined diagnosis codes for accuracy, completeness, specificity and appropriateness according to services rendered.
• Interpreted medical reports containing ICD-9, ICD-10, CPT and HCPCS codes.
• Evaluated accuracy of provider charges, including dates of service, procedures, level of care, locations, diagnoses, patient identification and provider signature.
• Carefully reviewed medical records for accuracy and completion as required by insurance companies.
• Appropriately and correctly identified errors and re-filed denied/rejected claims.
• Performed quality control of data entry system to verify that claims are processed correctly.
• Verify prior authorizations.
• Address and resolve new or unusual claim errors.
• Use appropriate documentation and reference materials to process claims accurately and efficiently.
• Complete daily war-room spreadsheets.