Sibazuli Amani
TX
Summary
Knowledgeable Senior Claims Auditor with seven years of medical experience. Offering expertise in investigation, litigation and settlements. Proficient in executing claims transactions and applying settlement protocols to foster timely, fair and accurate claims processing. Track record of superior performance in tea, leadership roles.
Adhering to CMS, Commercial Insurance guidelines and reprocessing claim reimbursement. Offering seven years of claims investigation expertise, including proficiency in AWS Health Rules Management. Strong knowledge of fair claims settlement practices and claims transactions.
Overview
8
8
years of professional experience
Work History
Senior Claims Analyst-Operations
UST HealthProof
11.2021 - 12.2023
- Knowledge of provider contracts, pricing systems, hospital data management . CPT, HCPCS, ICD-9 and ICD-10, UB04, CMS 1500
- Provider reimbursement analysis.
- Financial compliance audit.
- CMS Physician Fee Schedule. Medicare-Medicaid
- Evaluate each claim for appropriate coding of CPT and ICD codes against charges that are billed
- Claim payment and adjudication processing.
- Diligently review reports to ensure that no errors have been made in the appraisal process
- Claims configuration, adjudicates for provision of deductibles, co-pays, co-insurance maximums and provider settlements and Medicaid claims
- Review operations systems and procedures, recommend improvements to increase efficiency, and participate in projects to achieve optimization goals
- Evaluate each claim for appropriate coding of CPT and ICD codes against charges that are billed and enter
- Excellent knowledge of HCPCS, and ICD-9 coding bill on UB92, HCFA and electronic claims
- Interpreting state insurance laws and regulations to determine coverage eligibility and liability issues in cases involving injuries or damages
- Maintaining records related to claims processing, including case files, medical records, and legal documents
- Performed detailed medical reviews of prior authorization request, following established criteria and protocols.
- Applied knowledge of Medicare, Medicaid and third-party payer requirements utilizing on-line eligibility systems to verify patient coverage and policy limitations.
- Resolved complex claim issues by examining evidence, analyzing legal documents, and conducting investigations.
Medical Claims Auditor Team Lead–Contractor
Mindlance
Irving, TX
04.2020 - 03.2021
- Experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc
- Preferred
- Provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required
- In depth knowledge of UB04 and medical (1500) claim formats and requirements
- Project management skills
- Conceptual and analytical skills
- Microsoft Suite of products (Excel, Word, Access)
- Knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-9 codes and modifiers; and/or MSDRG, Revenue codes, and APCs.
Medical Claims Recovery l –Contractor
Christus Health
Irving, TX
08.2019 - 01.2020
- Responsible for posting hospital charges or other satellite services
- Utilizes correct ICD9, CPT and HCPCS coding methods to determine the proper code for the services rendered
- Responsible to contact Clinical departments and Medical Records in order to obtain information relevant to erred claims as possible Integrity issues
- Knowledge of Medicaid, Medicare Advantage, Tricare and Health Care Exchange
- Coordinates all Insurance Authorizations for the service
- Provides thorough, courteous and professional assistance to patients, physician offices, insurance companies and other clients on an as needed basis while maintaining strictest confidence
- Documents, forwards, resolves incoming mail and correspondence
- Subrogation Injury Development Cases-Potential TPL
Oncology Medical Secretary
USMD The Center For Cancer And Blood Disorders
Arlington, TX
03.2018 - 01.2019
- Performed departmental administrative duties to support the department director, medical staff, physician and trainees
- Held screening, triaging telephone calls, facilitating patient referrals, maintaining calendars, handling incoming mail, completing Chemo reports, explanation of benefits and filing medical records
- Charge entry and patient balance processing
- Perform responsibilities of scheduling patient's appointments with the concerned physician
- Perform transmittal of paperwork to appropriate areas in the department
- Responsible for checking patients out, collecting money and rescheduling follow-up appointments
- Handle the tasks of entering patient's information into computer
- Blood work, pharmacy prescription information, surgery schedule and prior authorization.
Medical Receptionist
Doctors’ Choice Urgent Care
Haslet, TX
11.2017 - 02.2018
- Check-in patients, Collect Co-pay, Update patient demographic, chief complaints and Insurance information
- Coordinate physician schedules and maintain patient flow by communicating patient arrivals or delays
- Use EMR software to manage patient records and files; reinforce and uphold patient confidentiality as required by HIPAA and clinic
- Manage office and medical supply inventories; receive deliveries and organize supplies in stockrooms and exam rooms
- Ordered diagnostic tests and communicate results to patients.
Duchenne Muscular Dystrophy Coordinator
AmerisourceBergen Specialty Group
Frisco, TX
04.2017 - 10.2017
- Coordinates the patient's care with physician offices, nurses, pharmacists and patients
- Performs insurance verification, both major medical and pharmacy benefits
- Coordinates prescription deliveries and refills for patients
- Works with home health nursing visits and maintenance of a patient census throughout the course of their therapy
- Supports other team members in the healthcare team
- Flag issues that need to be addressed
- Coordinates responses and resolutions to issues with appropriate internal and external parties
- Actively participates in roundtable discussions with Pharmacists, Nursing Services and Pharmacy Care Coordinators to review cases and related drug therapy and pharmacy care plan issues
- Maintains and promotes positive and professional working relationships with associates and management.
Member Service Specialist
Prime Therapeutics LLC
Irving, TX
10.2015 - 11.2016
- Inbound, Outbound calls
- Checking Eligibility Benefits
- Medical Claims, Local pharmacy claims
- Prescription refill orders
- Verify Prior Authorization
- (CoverMyMeds)
- Core Strengths
- Comprehensive knowledge of medical terminology and hospital administrative procedures
- Possess excellent interpersonal, organizational and management skills
- Schedules chemotherapy and radiation treatments plans along with tumor board meetings, travel, pharmaceutical drug vendors with our oncologist or physician's assistant
- Comprehensive knowledge of EMR Systems, Availity, Allscripts and CoverMyMeds
- Skilled in handling and responding in emergency situations
- Ability to work effectively with patients and physicians
- Assists in checking outpatients and assists them with referral processing and scheduling process
- Adheres to and supports the mission, purpose, philosophy, objectives, policies, and procedures of Tenet Physician Resources
- Managing physician surgical schedule as well as other business-related appointments.
Education
Bachelor of Science - Biology
Texas Woman’s University
Denton, TX12.2024
High School Diploma -
Winfree Academy Charter High School
Dallas, TXSkills
- AWS Healthedge Management, HRP
- Financial reimbursement compliance
- Claims Configuration
- Medical Claims Analyst
- Microsoft Office,Word, Excel, PowerPoint, Outlook, Access
- CMS Physician Pricing Contracts
- Professional and Institutional billing
- Operating systems - XP, Vista Enterprise, Windows 7, Mac OS
- Insurance and collections procedures
- Medicare Compliance
- Documentation and Reporting Deadlines
- HIPAA Compliance
- Data Management
- Statistic Analysis Expertise
- Medicaid Billing
- Project Management
- SOP Adherence
- Organizational Skills
- Risk Mitigation
- Medical History Recording
- Coding Error Resolution
- Hospital Inpatient and Outpatient Records
Accomplishments
- Basic Life Support for Healthcare Providers- conducted by: American Red Cross ID: 10SKQV
References
References Available Upon Request
Languages
Timeline
Senior Claims Analyst-Operations
UST HealthProof
11.2021 - 12.2023
Medical Claims Auditor Team Lead–Contractor
Mindlance
04.2020 - 03.2021
Medical Claims Recovery l –Contractor
Christus Health
08.2019 - 01.2020
Oncology Medical Secretary
USMD The Center For Cancer And Blood Disorders
03.2018 - 01.2019
Medical Receptionist
Doctors’ Choice Urgent Care
11.2017 - 02.2018
Duchenne Muscular Dystrophy Coordinator
AmerisourceBergen Specialty Group
04.2017 - 10.2017
Member Service Specialist
Prime Therapeutics LLC
10.2015 - 11.2016
Bachelor of Science - Biology
Texas Woman’s University
High School Diploma -
Winfree Academy Charter High School
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