Sheila Montoya
Hanford,CA
Summary
Proven expertise in medical coding and billing with almost 30 years of experience. Skilled in ICD-10 Coding and adept at interpersonal communication, Used sound, fact-based decision-making skills to render a decision for non-clinical complaints
Relayed appeal or grievance information to members, providers, and internal/external parties within the appropriate time frame
Reviewed all coding for accuracy on each claim to make sure claims were processed according to the contracts set forth between the hospital or provider. Excel in translating complex medical data into compliant coding, significantly reducing claim denials and enhancing revenue recovery.
Overview
28
28
years of professional experience
Work History
Medical Biller and Coder
John E. Weisenberger, M.D.
Hanford, CA
01.2013 - 04.2024
- Maintained strict confidentiality with adherence to HIPAA guidelines and regulations
- Reviewed outpatient records and interpreted documentation to identify diagnoses and procedures.
- Correctly coded and billed medical claims for various hospital and nursing facilities.
- Applied official coding conventions and rules from American Medical Association and Centers for Medicare and Medicaid Services to assign diagnostic codes.
- Interacted with physicians and other healthcare staff to ask questions regarding patient services.
- Increased coding accuracy by diligently reviewing medical documentation and applying appropriate codes.
- Performed on-site coding audits to determine accuracy and compliance with coding guidelines.
- Collaborated with physicians to obtain necessary documentation, improving claim approval rates.
- Researched and resolved medical record discrepancies.
- Followed up with medical staff regarding missing information in patient records.
- Assisted in preparation of medical reports for external parties.
- Communicated effectively with staff, patients, and insurance companies by email and telephone.
- Reviewed medical records for completeness and filed records in alphabetic and numeric order.
- Managed office operations while scheduling appointments for department managers.
- Handled sensitive information with discretion, maintaining confidentiality of company documents and personnel records.
- Collaborated with healthcare provider to ensure accurate documentation, leading to timely reimbursements for services rendered.
- Worked closely with physician to accurately assign ICD-10 diagnostic codes for optimal reimbursement rates from insurance companies.
- Supported patients experiencing personal challenges by offering guidance throughout their entire FMLA and Short Term Disability process of applying for and updating continuance of care.
- Supported patients transitioning to Medicare with their choices and any questions patient's might have.
Medical Billing Specialist
Dr. Au
Hanford, CA
09.2010 - 03.2012
- Maintained strict confidentiality with adherence to HIPAA guidelines and regulations.
- Analyzed complex Explanation of Benefits forms to verify correct billing of insurance carriers.
- Filed and updated patient information and medical records.
- Collected payments and applied to patient accounts.
- Liaised between patients, insurance companies, and billing office.
- Communicated with patients for unpaid claims for HMO, PPO and private accounts and delivered friendly follow-up calls for proper payments to contracts.
- Precisely evaluated and verified benefits and eligibility.
- Reviewed patient records, identified medical codes, and created invoices for billing purposes.
- Utilized various software programs to process customer payments.
- Collaborated with healthcare providers to obtain necessary documentation for accurate billing.
- Maintained up-to-date knowledge of coding standards, resulting in fewer errors and improved claim acceptance rates.
- Verified insurance of patients to determine eligibility.
- Resolved complex billing issues through meticulous research, collaboration with colleagues, and effective communication with insurance carriers.
- Successfully appealed denied claims by providing thorough documentation supporting necessity of billed services.
- Facilitated communication between healthcare providers and insurance companies, ensuring timely payment for services rendered.
- Communicated with insurance providers to resolve denied claims and resubmitted
- Communicated with insurance providers to resolve denied claims and resubmitted.
Insurance Billing Follow Up Manager
Valley Family Health Care
Riverdale, CA
04.2007 - 07.2009
- Applied HIPAA privacy and security regulations while handling patient information
- Accomplished multiple tasks within established timeframes.
- Managed and motivated employees to be productive and engaged in work.
- Cross-trained existing employees to maximize team agility and performance.
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
- Assisted in training junior medical billers, sharing expertise and best practices to improve overall team performance.
- Prevented financial delinquencies by working closely with managers to resolve billing issues before becoming unmanageable.
- Liaised between patients, insurance companies, and billing office.
- Audited and corrected billing and posting documents for accuracy.
- Reconciled accounts receivable to general ledger.
Senior Appeals Processor
Cigna
Visalia, CA
05.1996 - 03.2006
- Increased productivity by effectively managing workload and prioritizing tasks.
- Research appeals from providers and hospitals, log and track information as it moves through the clinical process or is tasked through internal contacts
- Contact provider or hospital to collect information and communicate disposition of each case, document all interactions
- Review cases to determine if it needs further review by a clinician
- Used sound, fact-based decision-making skills to render decisions for non-clinical complaints
- Specializing in high dollar hospital claims
- Relayed appeal or grievance information to members, providers, and internal/external parties within appropriate time frame
- Reviewed all coding for accuracy on each claim to make sure claims were processed according to contracts set forth between hospital or provider.
Education
Administrative Medical Assistant -
Golden State Business College
Visalia, CA2002
Skills
- Certified Medical Coder
- Verbal and Written Communication, Interpersonal Communication
- Medical Billing Processing
- Certified Medical Coder
- Attention to Detail, Time Management
- Word Processing Software
- Insurance Billing and claim submission
- Medical Terminology
- ICD-10 Coding and proficiency
- Doctor Communication
- HIPAA Compliance
- Insurance Verification
- Insurance Appeals and Denials processing
- Payment posting
- Medical Coding Expertise
- Medicare and Commercial Billing
- CMS-1500 Form Completion
- Proficiency in Office Ally
- Medical Billing
- Insurance coding (ICD-9 and CPT)
- Knowledgeable in Microsoft Word
- Insurance claims analysis
- Hospital Inpatient and Outpatient Records
Timeline
Medical Biller and Coder
John E. Weisenberger, M.D.
01.2013 - 04.2024
Medical Billing Specialist
Dr. Au
09.2010 - 03.2012
Insurance Billing Follow Up Manager
Valley Family Health Care
04.2007 - 07.2009
Senior Appeals Processor
Cigna
05.1996 - 03.2006
Administrative Medical Assistant -
Golden State Business College
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