Sheila Watson

Work History

Financial Clearance Specialist

MedaSource - Johns Hopkins Hospital

02.2023 - 08.2023

This was through Recruiting Service- Contract
Ensured all scheduled patients are financially cleared with health plans prior to date of service to protect financial well-being of organization
Ensured all scheduled services are authorized and appropriate notification and/or referral is obtained prior to date of service to ensure payment for services
Exception based, accurately calculated patient responsibility or patient liability estimate using appropriate tools and communicates financial responsibility to patient/guarantor based on insurance benefits as appropriate.
Performed activities that relate to financial clearance for multiple patient types (e.g. Inpatient Admissions, Diagnostic Outpatients, Ambulatory Surgery, Series accounts); communicate as needed with patients/ guarantors, and physicians/office staff in deployment of key activities
Determined if scheduled service (visit, procedure, admission) requires referral/authorization based on insurance payer requirements.
If required contacted PCP for referral/authorization, review referral for accuracy and completion of information, follow payer specific policies and procedures
Verified if patient does not have authorization or financial clearance 3 business days prior to scheduled date of service to follow organizational JHM Financial Clearance Override Policy
Reviewed scheduled service (visit, procedure, admission) for benefit carve outs or benefit limitations
Identified pre-certification requirements for elective, urgent & emergent admissions and outpatient services for all Payers (i.e. Primary, Secondary, Tertiary, etc.)
Clear and timely documentation of financial clearance activities and outcomes in Epic (using defined acronyms)
If clinical information or signed order was not complete, utilize EPIC to send In-Basket email to provider requesting information to complete authorization or secure electronic email notification. ·
Responded to all inquiries from patients, physicians or departmental customers (both internal and external) within 1 business day of initial request
Exception based, provided support to patients upon request for cost of procedures across JHM via price transparency tool found on JHM provider portal or walk patient through tool via MyChart link
Exception based, provide patients with price estimates upon request via patient estimates tool to support JHM customer service experience
Obtained accurate insurance benefits for elective, urgent & emergent admissions and outpatient services if not completed prior to service or at time of service

Provider Claims Service Representative

AmeriHealth Caritas Health Plan

10.2022 - 02.2023

This was through Recruiting service- Contract
Demonstrated passion for providing superior customer service to customers and providers and was able to understand needs of those served
Answered and responded to 40 provider calls and assisted with any inquiries in relation to eligibility, benefits and claims status.
Created accurate and timely documentation concerning all inquiries taken in accordance to established protocols to ensure resolution was provided and presented in clear and accurate manner.
Presented and projected positive image of company in and out of office to fellow associates, members, providers and community by being courteous, helpful, energetic, respectful and polite.
Strived to resolve inquiry on first contact while ensuring that inquiries have been addressed to customer's satisfaction by using all resources in efficient and timely manner. Followed-up with providers, if necessary, in timely fashion.
Communicated complex healthcare information in way that is understandable and relatable to providers. Pended claims requiring additional information and/or special handling; initiates action to obtain required information. Forwarded Service Forms requiring external department intervention to appropriate department person.
Monitored outstanding inquiries and worked with management staff to identify and resolve areas of non-compliance. Reviewed and verified quality audit reports. Reconciled audit discrepancies, corrected in system and made appropriate changes to avoid recurrence. Maintained thorough knowledge of claims process systems, its databases and subsystems

Financial Clearance Representative/Pre-Certificati

OSU Physicians Inc.

08.2017 - 08.2022

Used integrated health Information systems and telephone technology with customer service skills to facilitate customer interactions such that customer experienced Medical Center and its entities as accessible, coordinated, and seamless entity.
Obtained and entered accurate and complete patient registration data into EPIC. Confirmed and corrected billing address, subscriber, insurance plan, coordination of benefits and missing information in EPIC. Assured accurate information was gathered to support clinical and financial needs including changes to insurance and other patient information.
Performed accurate search for patients in EPIC data base, thus reducing duplicate patient records. Assessed patient's financial ability to pay for services, referring patients to financial counseling staff when appropriate.
Provided required clinical, insurance, and demographic information to payer to obtain precertification and assume benefit reimbursement. Requested and created referrals for specified population as required.
Obtained authorization numbers and entered into patient's account obtaining medical, ICD and CPT codes. Provided accurate information to billing and case management to assure payment of claims.
Contacted external companies to verify patient's employment and insurance information for Workers Compensation cases.
Displayed highest level of customer service, attentiveness, and consideration possible in all cases, keeping within standard set by Office of Compliance and HIPPA in reference to confidentiality.

Assistant Manager

Old Bag Of Nails LLC

07.2015 - 08.2016

Organized schedules, workflows and shift coverage to meet expected business demands.
Collaborated with store manager to develop strategies for achieving sales and profit goals in which sales were increased by 10%
Mentored staff to enhance skills and achieve daily targets, using hands-on and motivational leadership.
Coached team members and delivered constructive feedback to promote better productivity and build confidence.
Assisted supervisor in evaluating employee performance and cultivating improvement initiatives.
Completed thorough opening, closing and shift change functions to maintain operational standards each day.
Recruited and trained new employees to meet job requirements.
Delegated work to staff, setting priorities and goals.
Remained calm and professional in stressful circumstances and effectively diffused tense situations.
Maintained inventory accuracy by counting stock-on-hand and reconciling discrepancies.
Delegated daily tasks to team members to optimize group productivity.

Deputy Clerk of the Court

Licking County Domestic Court

05.2013 - 08.2013

This was Part-Time Position
Fulfilled document requests by citizens, parties to cases, judges and attorneys, keeping records of documents provided.
Tracked cases and managed electronic and physical records, creating new case files, entering filings, hearings, trials and judgments and closing cases when complete.
Answered face-to-face and telephone requests for information about warrants, citations and other court documents or procedures.
Prepared and issued summons, complaints, warrants and other documents necessary for daily courtroom operations.
Assembled paperwork and relevant files and briefs for use by judge at hearings and trials, using discretion to indicate key information relevant to judgment and prosecution decisions.
Acted as court cashier, processing billing and payments for fines, bonds, bail and other court fees, also recording details of payment and reporting missed deadlines or delinquency.
Liaised with general public to process document requests and provide customer service by phone or email and in person, keeping records of payments and documents provided.

Member Service Specialist

Molina Healthcare

05.2013 - 08.2013

Answered incoming calls and emails, providing frontline customer support or assistance with product and service transactions.
Demonstrated excellent communication skills in resolving product and consumer complaints.
Remained calm and professional in stressful circumstances and effectively diffused tense situations.
Consulted with customers to resolve service and billing issues.
Escalated customer concerns, issues and requirements to supervisors for immediate rectification.
Documented customer correspondence in CRM to track requests, problems and solutions.
Relayed customer feedback to cross-functional teams to improve products and services.
Organized and prioritized tasks and activities and worked within strict timeframes and deadlines.

Claims Processing Specialist

MedBen

10.2000 - 01.2013

Verified claim data correctness in preparation for processing.
Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
Reviewed history records to determine benefit eligibility for services.
Researched medical claims for validity to resolve discrepancies.
Analyzed contracts and claim systems to apply appropriate benefit amounts.
Coordinated benefits with medical insurance plans and Medicare providers.
Conducted and documented comprehensive investigations to negotiate settlements or deny claims.
Processed claims for payment or forwarded to appropriate personnel for further investigation
Checked documentation for appropriate coding, catching errors and making revisions.
Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
Precisely calculated refunds, premiums and adjustments.
Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
Sent clinical request and missing information letters to obtain incomplete information.

Summary

Overview

Work History

Financial Clearance Specialist

Provider Claims Service Representative

Financial Clearance Representative/Pre-Certificati

Assistant Manager

Deputy Clerk of the Court

Member Service Specialist

Claims Processing Specialist

Education

High School Diploma -

Skills

Timeline

Similar Profiles

Toshia LittleToshia Little

Tonya WaltonTonya Walton

Lisa AddisonLisa Addison

Jesse FogleJesse Fogle

Mouhamed GueyeMouhamed Gueye