Theresa L Powers
Santee,CA
Summary
"Extensive experience in the healthcare industry has included the following: Medical data entry and billing, Medical coding (ICD-9, CPT, HCPC Codes) and Referral management, Patient relations, Correspondence with insurance companies and patients Accounts receivables Detail oriented Office management Coaching Problem solving HIPAA Lead Representative Experience with TriCare, MediCare, Medi-Cal Training of new employees"
Overview
28
28
years of professional experience
Work History
Medical Biller; Referral Clerk; Front Desk
Family Practice Associates
San Diego, CA
- Processed referrals for all HMO, PPO and Medi-Cal insurance plans.
- Contacted servicing specialty providers to schedule appointments and obtain any needed clinical information for authorization requests to process.
- Entered charges and posted patient insurance payments.
- Reconciled denied services on Explanation of Benefits
- Checked patients in and out. Took Copays for office visits.
- Scheduled appointments and follow-up appointments
Billing & Collections Rep
Rady Childrens Specialists of San Diego A Medical Foundation
01.2024 - 02.2026
- Specialty: Multi-Physician Specialties (Ortho)
- Work denials/claim rejects/no response claims from 3 separate work queues.
- Identify, when billing for Fracture Care, what codes are bundled and what Codes are not bundled. Knowing which modifiers are needed to unbundle denied codes.
- From EncoderPro, review what Modifiers are acceptable for the codes being denied.
- Check that Authorizations are on the claim & that all codes billed are authorized. If codes billed are not on Existing Authorization, check with Insurance Carrier if Retro Auth Request is allowed.
- Request Retro Authorizations from Insurances that allow Retro Authorizations.
- Submitting Claim Disputes online with Insurance’s that have Dispute capability.
- Completing Provider Disputes on Paper & submitting with documentation.
- Checking California Childrens Services for active Service Authorizations for specific specialty. If active SAR is not found, Request for SAR for specific Specialty is submitted with medical records. If active SAR for specialty is found But code being billed is not listed, a SAR Modification Request is submitted requesting specific codes not listed in the Service Code Grouping.
Billing Specialist
Ventra Health
San Diego, CA
09.2016 - 10.2023
- Specialty: Anesthesiologists
- Working from Tricare Denials from Queue for coding errors and corrected claims.
- Verifying CCS charge tickets in a batch for Anesthesia Time, Modifiers are Correct for claim to bill correctly.
- Verifying Medi-Cal Eligibility and CCS Authorized SARs for approved services. Checking CCS Pedi for pended SAR’s, submitting SAR Modification Requests via PEDI eSAR requesting Nerve Block Procedures & TEE’s be added to SAR. Checking status of Pended SAR’s, fax needed documentation for review
- Working Out of State Medicaid Claims, calling for patient eligibility, obtaining correct Claims billing addresses and claim specific requirements. Going to Specific Out-of-State Medicaid Websites, looking up Conversion Factor for Anesthesia Rates, looking for Fee-for-Service Fee Schedule for allowed amounts on Non-ASA Codes
Medi-Cal Biller
Watland Billing Consultants
San Diego, CA
04.2015 - 07.2016
- Specialty: Anesthesiologists
- Processing of RAD Denials
- Writing CIF’s and Appeals for claims denied past the six months billing limit.
- Writing PDR’s for all claims denied by HMO/PPO Insurance Plans.
- Checking patient eligibility online & claim status online.
Medical Biller
Practice Development Strategies
San Diego, CA
05.2014 - 01.2015
- Specialties: Allergy, Dermatology, Infectious Disease & Psychiatry
- Review charge & payment batches for correct postings
- Identify and resolve patient, clerical staff & insurance billing complaints
- Review & correct claims to various insurance companies electronically or by paper
- Prepare and submission of refund requests to patients and insurance companies
- Daily charge queries for multiple practices (non-pays, denials appeals)
- Knowledge of billing MediCare, MediCal, Commercial, Private Insurances & EA Health
Customer Service Referral Representative @ NMCSD TSC
Equity Staffing/United HealthCare Military & Veterans
San Diego, CA
01.2014 - 03.2014
- Provides on-site customer service support to TSC walk-in customers with enrollment, benefits, access to care, claims, billing issues and appropriate program education as part of each beneficiary interaction. The representative reports to a TSC Manager or TSC Supervisor, depending on the size of the site.
- Keeps up-to-date on Military Treatment Facility (MTF) priorities and initiatives, TRICARE Program changes to enable accurate and timely information sharing.
- Delivers personalized information and assists with coordination in complex enrollment, access and claims problems.
- Performs other TSC Customer service support functions and administrative duties (such as data entry of referrals) as assigned.
Benefit Services Representative
TriWest Healthcare Alliance
San Diego, CA
02.2006 - 03.2013
- Processed referral requests from Military Treatment Facilities, Treatment Service Centers and Civilian Providers. Coded referral requests. Checked eligibility on specific insurance plan codes using the TriCare eligibility system. Trained new employees on referral requests into the medical management system. Assumed role of Lead Representative responsible for processing urgent requests daily. Responsible for completing the Pends Report, ensuring that all issues were resolved in order for referral requests to process and ensuring that team members were meeting reporting deadlines.
Medical Biller/Operator
Internal Medicine Association
San Diego, CA
02.2001 - 04.2005
- Posted patient and insurance payments.
- Reconciled claims for Explanation of Benefits for past due invoices.
- Worked Accounts Receivable reports.
- Balanced daily payment and adjustment reports. Made bank deposits.
- Handled incoming calls on seven-phone line system.
Medical Biller
Practice Development Strategies
San Diego, CA
08.1998 - 02.2001
- Specialties: Family Practice-Adult/Pediatrics
- Managed office for two-doctor practice including handling charges, payments, mailing claims and secondary claims.
- Processed Accounts Receivable, filed Children’s Health and Disability Preventative forms and electronically filed MediCare and Medi-Cal claims.
- Responded to patients’ inquiries regarding their accounts.
Education
CERTIFICATION - Microsoft Word Excel PowerPoint, Basic Windows
FOOTHILLS ADULT CENTER
06-2013
DIPLOMA - General Education, Office Assistant
MONTE VISTA HIGH SCHOOL
CERTIFICATION - Medical Terminology, Medical Records
SAN DIEGO SKILLS CENTER
10-1974
Skills
- Medical data entry and billing
- Medical coding (ICD-9, CPT, HCPC Codes)
- Referral management
- Patient relations
- Correspondence with insurance companies and patients
- Accounts receivables
- Detail oriented
- Office management
- Problem Solving
- HIPAA
- Lead Representative
- Experience with TriCare, MediCare, Medi-Cal
- Training of new employees
- Computer skills: MS Office
- Medical management systems: HealthPac, PBMS, Office Ally, Hospital Webs, MedPoint, ClearGage Payment, MTBC Soft, Lytec, Trizetto, Validator, InstaMed, Encoder Pro, Availity & NaviNet ((CCM, PCH, WEBDOES, CareRadius, MAXMC, WRDA, DEERS, Fax Browser, Medical Manager, Medic, Senco, Medisoft) MedSuite, CCS Pedi System, Rady Childrens Care Link, Scripps Epic Link, Emdeon-Change Healthcare, HealthCare Systems Payment, Epic Computer System for Patient Billing &Claims
Timeline
Billing & Collections Rep
Rady Childrens Specialists of San Diego A Medical Foundation
01.2024 - 02.2026
Billing Specialist
Ventra Health
09.2016 - 10.2023
Medi-Cal Biller
Watland Billing Consultants
04.2015 - 07.2016
Medical Biller
Practice Development Strategies
05.2014 - 01.2015
Customer Service Referral Representative @ NMCSD TSC
Equity Staffing/United HealthCare Military & Veterans
01.2014 - 03.2014
Benefit Services Representative
TriWest Healthcare Alliance
02.2006 - 03.2013
Medical Biller/Operator
Internal Medicine Association
02.2001 - 04.2005
Medical Biller
Practice Development Strategies
08.1998 - 02.2001
Medical Biller; Referral Clerk; Front Desk
Family Practice Associates
DIPLOMA - General Education, Office Assistant
MONTE VISTA HIGH SCHOOL
CERTIFICATION - Medical Terminology, Medical Records
SAN DIEGO SKILLS CENTER
CERTIFICATION - Microsoft Word Excel PowerPoint, Basic Windows
FOOTHILLS ADULT CENTER
URL Addresses
- LinkedIn: http://www.linkedin.com/pub/theresa-l-powers/6b/aa4/b84
- Beyond: http://www.beyond.com/PowersT-CA