SHARON GILLESPIE
Lewisville
Summary
Meticulous appeals, coding, and billing specialist with sound knowledge of billing systems for collecting, posting and managing account payments. In-depth expertise of analytical reviews submitting claims, following up with insurance companies and filing appeals for denials.
Overview
36
36
years of professional experience
1
1
Certification
Work History
Medical Coding Appeals Analyst Sr
Elevance Health
01.2022 - Current
- Reviewed coding and documentation for provider appeals to determine accuracy and compliance with regulations.
- Perform E&M Leveling audits.
- Consistently exceeds most performance goals, expected behaviors, and impact goals.
Denials Specialist
Ensemble Health Partners
01.2021 - Current
- Research coding rejections, by maintaining knowledge of CPT-4 and ICD-10 coding principles
- Investigate denials to appeal claims.
- Maintain knowledge of government regulations of Medicare, Medicaid, and third-party regulations and requirements for regarding billing commercial insurance for multiple states.
Coding Billing Specialist
Heart of Ohio Family Healthcare
11.2019 - Current
- Performs ongoing prospective coding and documentation chart reviews for physician services to ensure that the coding supports the services billed.
- Follow Federally Qualified Health Centers guidelines and regulations.
- Resolve related coding issues in all phases: production, coding scrub, and coding denial resolution.
- Maintain consistent quality using the established coding guidelines provided by the immediate supervisor.
Oncology Reimbursement Specialist
Fairfield Medical Center
04.2017 - 11.2019
- Outpatient hospital and chemotherapy coding.
- Attended seminars to remain up-to-date with coding guidelines and reimbursement requirements.
- Determined medical necessity, using individual insurance carrier regulations.
- Researched rejections, investigating problems to appeal claims.
- Advised supervisors and clinicians of billing deficiencies to support charge capture.
Technical Appeals Analyst
Fairfield Medical Center
07.2014 - 04.2017
- Reviewed medical coding and medica necessity of procedures performed.
- Recovered $3.0 million in 2017 and $3.5 million in 2018 by appealing denied claims for medical necessity, timely filing, incorrect reimbursement, etc.
- Determined insurance coverage levels and restrictions by thoroughly examining claims forms and associated records.
- Created master spreadsheet to record procedures, denials and approvals.
Appeals Coordinator
Mount Carmel Medical Center
02.2013 - 07.2014
- Meticulously identified and rectified inconsistencies, deficiencies and discrepancies in medical documentation and coding.
- Recovered over $2 million in reimbursement appealing claim denials for BWC, commercial insurances and third party claims.
- Analyzed insurance organizational structures, business and intermediaries; studied basic documents, including common clauses, policies and insurance contracts.
Supervisor
Kmart
11.2013 - 02.2014
- Oversaw the workflow of 15-20 employees.
- Trained new employees on different areas of the store.
Reimbursement Specialist
Mercy Medical Center
11.2011 - 02.2013
- Researched rejections, investigating problems to appeal claims.
- Maintained knowledge of CPT-4 and ICD-9 coding principles; government regulations of Medicare, Medicaid, and BWC; protocols and third-party requirements regarding billing commercial insurance.
- Maintained 99.8% quality, 99.9% quantity and 98% on audits.
- Determined medical necessity, using individual insurance carrier regulations.
Registration Team Lead
Southeastern Ohio Regional Medical Center
06.2008 - 11.2011
- Facilitated the patient access process to the Emergency Department Registered patients for in- patient and outpatient services.
- Devoted special emphasis to punctuality and worked to maintain outstanding attendance record, consistently arriving to work ready to start immediately.
- Evaluated employee performance, identified areas of improvement and communicated plans to employees.
Commercial Research Analyst / Denial Management
Southeastern Ohio Regional Medical Center
02.2005 - 06.2008
- Researched CPT-4 and ICD-9 coding discrepancies for compliance and reimbursement accuracy.
- Confidently and adeptly handled claim denials and/or appeals.
Medical Insurance Claims Auditor
Central Benefits
02.1990 - 06.2006
- Audited medical claims for correct CPT and ICD-9 coding principles, government regulation, protocols and thirdparty requirements according to each employer's health insurance plan.
- Maintained 99.9% quality, 99.9% quantity and 98.9% financial on audits.
- Assessed insurance claims and reviewed eligibility information for members to determine if payments had been properly made.
Education
Associate of Applied Science - Health Information Management Technology
State Community College
Columbus, OH05.2019
Skills
- Medical Coding
- Insurance Billing
- Chemotherapy Coding and Billing
- Financial Reimbursement
- Teamwork/Collaboration
- Customer Contact
- Denials & Appeals Specialist
- Medicare and Ohio Medicaid regulations
- Strong work ethics
- Clinical and billing documentation and reimbursement
- Equipment Set Up
- Medical insurance specialist
- Case evaluation
- Verbal communication
- Legal research
- Policy interpretation
Certification
- Registered Health Information Technician (RHIT) – taking test in September
- Certified Professional Coder (CPC)
- Certified Revenue Cycle Representative (CRCR)
Timeline
Medical Coding Appeals Analyst Sr
Elevance Health
01.2022 - Current
Denials Specialist
Ensemble Health Partners
01.2021 - Current
Coding Billing Specialist
Heart of Ohio Family Healthcare
11.2019 - Current
Oncology Reimbursement Specialist
Fairfield Medical Center
04.2017 - 11.2019
Technical Appeals Analyst
Fairfield Medical Center
07.2014 - 04.2017
Supervisor
Kmart
11.2013 - 02.2014
Appeals Coordinator
Mount Carmel Medical Center
02.2013 - 07.2014
Reimbursement Specialist
Mercy Medical Center
11.2011 - 02.2013
Registration Team Lead
Southeastern Ohio Regional Medical Center
06.2008 - 11.2011
Commercial Research Analyst / Denial Management
Southeastern Ohio Regional Medical Center
02.2005 - 06.2008
Medical Insurance Claims Auditor
Central Benefits
02.1990 - 06.2006
Associate of Applied Science - Health Information Management Technology
State Community College