THEADORA NUNEZ
Beaufort,SC
Summary
Medical billing and revenue cycle professional focused on claims management and insurance verification. Analyzes denial trends and implements corrective actions to improve reimbursement outcomes. Develops and streamlines billing and credentialing policies to support operational efficiency and compliance.
Overview
7
7
years of professional experience
Work History
Billing and Credentialing Manager
SAFE PLACE BEDDING
08.2024 - Current
- Credentialed healthcare providers for Medicare and Medicaid programs. with Medicare, Medicaid, and commercial insurance plans.
- Manage billing for DME products, including miscellaneous HCPCS codes.
- Verify insurance eligibility and benefits for patients.
- Review claims for accuracy and ensure clean claim submission.
- Researched and appealed denied and rejected claims, enhancing reimbursement outcomes.
- Analyzed denial trends and implemented corrective actions to reduce future denials.
- Develop billing, credentialing, compliance, and patient intake policies and procedures.
- Process worklists and resolve insurance denials while ensuring timely filing compliance.
- Research EOBs and document payer correspondence regarding coverage and reimbursement.
- Acted as liaison among patients, providers, and insurance carriers to resolve billing inquiries efficiently.
Medical Insurance Authorization & Claims Follow-Up Representative
MEDICAL BILLING FOR DENTISTS
12.2024 - 03.2026
- Prepared, reviewed, and submitted prior authorization documentation.
- Verified provider benefits and insurance coverage to ensure proper authorization.
- Followed up on pending authorizations and insurance claims to expedite resolution.
- Ensured documentation met payer requirements for approval, facilitating timely access to treatments.
- Verified insurance eligibility for mandibular advancement devices used to treat sleep apnea.
- Submitted GAP exception requests.
- Reviewed and managed documentation for compliance and accuracy.
Denials Management Specialist
MEDCENTRIS
04.2024 - 08.2024
- Identified denial trends and developed corrective action plans to address root causes.
- Investigated insurance denials and coordinated recovery efforts.
- Processed denial worklists and appealed denied claims.
- Audited patient accounts for coding, benefits, and reimbursement accuracy.
- Created reporting tools that streamlined denial management processes and enhanced data visibility.
- Collaborated with leadership to implement strategies that strengthened reimbursement performance.
- Monitored insurance updates between registration and billing systems.
Quality Assurance Specialist – Adjustments & Refunds
BRIGHTREE LLC
03.2024 - 04.2024
- Conducted quality audits for billing adjustments, refunds, and rebills to ensure accuracy and compliance.
- Monitored adherence to quality standards and service level agreements to maintain high service quality.
- Reviewed and managed documents for accuracy and compliance.
- Identified trends and process deficiencies.
- Updated procedures and recommended workflow improvements.
- Assisted with staff education and implementation of new procedures.
- Partnered with departments to streamline processes and enhance overall operational efficiency.
Patient Financial Services - Biller
BEAUFORT MEMORIAL HOSPITAL
03.2024 - 03.2024
- Managed patient accounts using Meditech, Quadex, and Athena systems to uphold accurate financial records
- Prepared and submitted UB-04 claim forms with precision to facilitate efficient claims processing
- Analyzed and resolved rejections and denials on hospital claims to ensure timely reimbursement
Billing Representative
NORTH FLORIDA MEDICAL
06.2023 - 02.2024
- Verified insurance eligibility and secured prior authorizations to facilitate timely claim processing.
- Processed DME claims using Brightree.
- Investigated and resolved claim denials to ensure appropriate reimbursement for services rendered.
- Collected patient payments and organized account documentation to maintain accurate billing records.
- Communicated with patients and insurance companies regarding billing and reimbursement.
- Posted payments and reconciled accounts using EOBs and ERNs.
- Maintained patient records within the EHR.
- Reviewed physician orders for coding accuracy.
- Reviewed and organized documents for accuracy and compliance.
Account Manager
PLATINUM VENTURE GROUP
08.2019 - 10.2023
- Credentialled providers with insurance networks to expand service offerings and improve patient access.
- Verified insurance eligibility and resolved claim denials.
- Resolved billing inquiries through exceptional customer service, enhancing client satisfaction and trust.
- Managed DME billing and coding operations.
- Reviewed and managed documents to ensure accuracy and compliance with regulatory standards.
- Maintained DME pricing catalogs and fee schedules.
- Reconciled payments using EOBs and ERNs.
Education
Medical Billing & Coding Certification -
Texas A&M International University
Laredo, TXBachelor of Science - Communication
University of Utah
Salt Lake City, UTSkills
- Billing and coding
- Claims management
- Insurance verification
- Authorization management
- Appeals management
- Medicare and Medicaid
- Commercial insurance management
- Reconciliation processes
- Payment posting
- ICD coding
- ICD-10-CM
- HCPCS Level II
- Brightree proficiency
- Electronic Data Interchange (EDI)
- Revenue Cycle Management (RCM) Systems
- Insurance Provider Portals
- Regulatory compliance management strategies
- Root cause analysis
- Process improvement
- Healthcare experience
- Policy development
- Efficiency improvement
- Revenue management
- Client relations
- Office applications
- Microsoft Excel
- Microsoft Word
- Microsoft Outlook
- EDI knowledge
- Analytical skills
- Reporting skills
- Analytical skills
- Reporting skills
Timeline
Medical Insurance Authorization & Claims Follow-Up Representative
MEDICAL BILLING FOR DENTISTS
12.2024 - 03.2026
Billing and Credentialing Manager
SAFE PLACE BEDDING
08.2024 - Current
Denials Management Specialist
MEDCENTRIS
04.2024 - 08.2024
Quality Assurance Specialist – Adjustments & Refunds
BRIGHTREE LLC
03.2024 - 04.2024
Patient Financial Services - Biller
BEAUFORT MEMORIAL HOSPITAL
03.2024 - 03.2024
Billing Representative
NORTH FLORIDA MEDICAL
06.2023 - 02.2024
Account Manager
PLATINUM VENTURE GROUP
08.2019 - 10.2023
Medical Billing & Coding Certification -
Texas A&M International University
Bachelor of Science - Communication
University of Utah