Years of Medical Billing experience
Toccara Thomas
Medical Billing | Administrative Professional
Houston,TX
Summary
Highly experienced and detail-oriented medical billing professional with 18 years of proven success in revenue cycle management, now seeking to leverage extensive knowledge in a Refund Specialist role. Proficient in government and managed care payment methodologies, adept at analyzing complex payment data, and skilled in identifying and processing contractual adjustments, allowed amounts, and coinsurance. Proven ability to research denials, and optimize denial processes to ensure accurate payment reconciliation, and adherence to compliance standards.
Overview
18
18
Work History
Medical Billing and Collections Specialist
ScionHealth (formerly Kindred Healthcare)
Houston
03.2012 - 10.2024
- Managed the preparation and submission of medical documentation to ensure compliance with insurance regulations for funding approvals, aligning with fraud prevention standards.
- Identified and processed overpayments, initiating and reconciling refunds in compliance with client policies, and financial regulations.
- Communicated effectively with internal teams regarding order processing, while maintaining high standards of customer service, to resolve potential fraudulent activities.
- Utilized electronic remittance advice (835) reconciliation to identify variances between billed charges, allowed amounts, and payments received, ensuring accurate financial postings.
- Utilized technology, such as online portals, to verify patient insurance eligibility efficiently, securing accounts to prevent losses.
- Established a 98% collection rate within the first year by structuring all new claims to have a turnaround time of 72 hours, demonstrating strong monitoring skills.
- Collected reimbursement for billed, aged accounts.
- Researched and resolved complex account discrepancies, including overpayments and underpayments, ensuring accurate application of contractual adjustments and allowed amounts to maximize reimbursement, and prevent unauthorized charges.
- Managed comprehensive denial processes, meticulously researching root causes for claim rejections, and successfully appealing previously denied claims by gathering necessary documentation and collaborating with payers to secure appropriate reimbursement.
- Identified and resolved insurance coverage issues, including discrepancies in patient demographics, policy numbers, and plan details.
- Obtained necessary authorizations and pre-certifications for medical procedures to ensure timely reimbursement.
- Maintained up-to-date knowledge of insurance regulations and policies, including HIPAA compliance.
Claims Auditor
PFS Group
Houston
01.2011 - 03.2012
- Analyzed medical claims for accuracy, identifying discrepancies related to contractual adjustments, allowed amounts, and coinsurance calculations, and mitigating potential fraud.
- Reviewed supporting documentation to ensure compliance with insurance regulations.
- Communicated effectively with healthcare providers and internal departments to resolve claim discrepancies.
- Identified opportunities for process improvement to streamline claim processing.
- Provided guidance and training to team members on claim review procedures and best practices.
Medical Claims Specialist
Benefit Recovery Specialists
Houston
08.2008 - 12.2010
- Managed and processed a high volume of medical claims, averaging 150 claims daily, primarily for diverse commercial insurance carriers, including Aetna, Blue Cross Blue Shield, UnitedHealthcare, Cigna, Humana, etc., ensuring 98%+ accuracy and strict adherence to specific payer guidelines.
- Spearheaded the analysis of denial patterns for commercial claims, identifying root causes, and implementing proactive strategies that reduced claim rejections by 20%, demonstrating expertise in optimizing denial processes.
- Expertly resolved complex commercial billing discrepancies, including issues related to contractual adjustments and allowed amounts, successfully appealing over 90% of denied claims by meticulously gathering supporting clinical documentation and engaging in effective communication with commercial insurance adjusters.
- Proactively verified patient insurance eligibility and benefits, including coinsurance responsibilities, for thousands of commercial plans, demonstrating comprehensive knowledge of diverse managed care payment methodologies, and payer policies.
- Applied extensive and up-to-date knowledge of CPT, ICD-10, and HCPCS codes to ensure precise claim submission, optimize reimbursement, and mitigate audit risks across all commercial claim lines.
- Consistently maintained strict adherence to HIPAA regulations, PHI protection protocols, and evolving healthcare compliance standards, safeguarding patient privacy and organizational integrity.
- Collaborated effectively with front office teams and patients to investigate and resolve complex commercial billing inquiries, leveraging strong written and verbal communication skills to explain intricate insurance processes clearly and concisely.
- Managed a significant accounts receivable portfolio for commercial payers, diligently following up on outstanding claims, initiating appeals, and processing resubmissions to accelerate revenue collection and minimize aged accounts.
Education
Bachelor of Science - Business Management
Full Sail University
Winter Park, FL05-2019
High School Diploma -
Westfield High School
Houston, TX05-2001
Skills
- Patient billing assistance
- Data entry efficiency
- Debt recovery expertise
- Availity
- Change Healthcare (Emdeon)
- SSI
- CPT, ICD-10-CM, HCPCS Level II
- Medicare and Medicaid regulations
- Commercial payer guidelines
- Eligibility and benefits verification
- HIPAA Regulations
- Electronic claim submission (837)
- Electronic Remittance Advice (835)
- Denial management and appeals
- Discrepancy resolution
- Payment reconciliation and refund processing
- Managed care payment methodologies
- Microsoft Office Suite (Word, Excel, Outlook)
- Google Suite
- Professional communication
- Medical billing software proficiency
- Insurance verification
- Attention to detail
- Payment processing
- Problem solving
- Time management
- Multitasking Abilities
- Interpersonal communication
- Analytical
- Accounts receivable
- Customer service
- Regulatory compliance
- Data analysis
- Team collaboration
- Electronic health records experience
- Claims processing proficiency
Accomplishments
Visionary Implementer Award | GFODT Church - Houston, TX April 2023
• Ability to see the big picture and identify opportunities for improvement or growth, in addition to having a
clear understanding of the desired outcome and able to articulate it effecti
• Proficient in identifying and mobilizing necessary resources, including people, funding, and materials, to
support projects or programs
• Adept at effectively leading and motivating teams, fostering collaboration and ensuring everyone is working
towards the same goal.
• Experienced in anticipating potential challenges and develop creative solutions to overcome obstacles.
• Perform a high level of commitment to seeing projects through to completion, even in the face of adversity.
References
References available upon request.
Certification
- CPAT Certified, Skill Category: Healthcare
- Skill Subcategory: Medical Billing and Coding
Work Preference
Work Type
Full TimeContract WorkWork Location
RemoteImportant To Me
Work-life balanceFlexible work hoursHealthcare benefitsWork from home optionPaid time offPaid sick leave401k matchQuote
The real test is not whether you avoid this failure, because you won’t. It’s whether you let it harden or shame you into inaction, or whether you learn from it; whether you choose to persevere.
Barack Obama
Languages
English
Native language
Interests
Creative Design & Visual Branding
Content Strategy & Marketing
Faith & Empowerment
Entrepreneurship & Personal Development
Music & Storytelling
Home & Lifestyle Aesthetics
Timeline
Medical Billing and Collections Specialist
ScionHealth (formerly Kindred Healthcare)
03.2012 - 10.2024
Claims Auditor
PFS Group
01.2011 - 03.2012
Medical Claims Specialist
Benefit Recovery Specialists
08.2008 - 12.2010
Bachelor of Science - Business Management
Full Sail University
High School Diploma -
Westfield High School
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