Tania Rojas

• Evaluated and analyzed reviews for accuracy and compliance with company standards.
• Collaborated with cross-functional teams to enhance review processes and guidelines.
• Developed training materials to onboard new staff on review protocols and systems.

• Manage high-volume case workflow, ensuring all documentation meets regulatory and policy requirements prior to submission

• Review clinical reports for accuracy, completeness, and compliance with Medicare and client-specific guidelines

• Coordinate with external partners to obtain missing documentation and resolve discrepancies

• Prioritize and manage multiple cases simultaneously to meet strict deadlines and service level requirements

• Maintain detailed case tracking logs to ensure timely processing and audit readiness

• Upload finalized determinations into multiple systems within strict deadlines

• Identify and correct report inconsistencies including demographics and documentation gaps

• Ensure HIPAA-compliant handling of sensitive patient information

• Mailed medical bills and determined pricing based on EOB
• Organized and kept track of self-pays that were mailed out manually
• Improved patient financial experiences by providing comprehensive guidance on payment options and assistance programs.
• Coordinated with other departments to address any discrepancies or concerns related to charge capture or data entry accuracy.
• Enhanced claim processing efficiency by verifying insurance coverage and obtaining pre-authorizations for procedures.
• Reduced errors in billing by accurately maintaining patient records with updated insurance information.
• Increased patient satisfaction by promptly addressing concerns regarding insurance coverage or billing issues.
• Achieved timely resolution of outstanding accounts through diligent follow-ups and negotiations with patients or their representatives.
• Collaborated with clinical staff to ensure accurate coding and billing procedures, mitigating discrepancies and minimizing claim denials.

• Precisely evaluated and verified benefits and eligibility
• Examined patients' insurance coverage, deductibles, insurance carrier payments and remaining balances not covered under policies when applicable
• Researched CPT and ICD-9 coding discrepancies for compliance and reimbursement accuracy
• Reviewed and verified data, including addresses, phone numbers, names, ages, and values
• Answered telephone calls to field inquiries from clients, vendors and various other callers seeking information
• Modified, updated and processed existing policies
• Assured timely verification of insurance benefits prior to patient procedures or appointments
• Maintained strong knowledge of basic medical terminology to better understand services and procedures
• Made contact with insurance carriers to discuss policies and individual patient benefits
• Observed strict procedures to protect sensitive patient information, including medical records and payment data.

• Reviewed and corrected claim errors to facilitate smooth processing
• Have worked for 2 different Hospital billing departments
• Multitasked between 2 different Hospital systems, depending on the call
• Collected forms, insurance card and co-pay to facilitate registration process and prepare patient for appointment
• Generated monthly statements to check outstanding balances
• Verified insurance coverage by telephone and online to guarantee proper reimbursement of benefits and estimate patients' financial responsibilities
• Contacted insurance companies to discuss and resolve unpaid claims and incorrectly paid claims
• Went over Patients EOB's to help resolve any disputes and confusions
• Proficient in using old and new Hospital software like Epic and NextGen