Tonya Rainer
Richmond,Tx
Summary
I am enthusiastic and eager to contribute to team success through hard work, diligence, and excellent organizational skills. I am motivated to learn, grow, and excel with your company. I have over 26 years of healthcare clinical experience in multiple settings. I can manage multiple projects efficiently, prioritize tasks, meet deadlines, and achieve objectives. I lead by example, providing team-building skills and planning with strong critical thinking skills and the ability to train others on new and emerging technologies and operational protocols.
Overview
15
15
years of professional experience
Work History
Insurance Claims Auditor
SCS Inc.
07.2023 - 04.2024
- Worked with Insurance companies with knowledge of UB Billing and CPT, Revenue, and ICD coding
- Reviewed aged accounts and traced and appealed unpaid and/or erroneously paid or denied accounts
- Prepared data entry and promptly submitted billing data and medical claims to insurance companies
- Monitored and recorded delinquent payments
- Followed up on missed payments and resolved financial discrepancies
- Examine patient bills for accuracy and request any missing information
- Meeting and maintaining production and quality expectations for all assigned measures
Department Coordinator Finance
MHS
05.2022 - 10.2023
- Worked with Insurance companies with knowledge of UB Billing and CPT, Revenue, and ICD coding
- Reviewed aged accounts and traced and appealed unpaid and/or erroneously paid or denied accounts
- Meeting and maintaining production and quality expectations for all assigned measures HEDIS
- Worked denials and underpayments received
- Worked tickler accounts daily to ensure the overall health of client accounts receivable
- Reviewed and addressed daily correspondence, including emails from clients
- Identified trends and inform client lead/manager, as appropriate
- Escalated issues to client lead/manager, as appropriate
- Prepared data entry and promptly submitted billing data and medical claims to insurance companies
- Prepared bills and invoices and documented amounts due to medical procedures and services
- Applied HEDIS concepts and principles in completing the abstraction and review process to ensure full recognition of delivered care for the member's benefit
- Monitored and recorded delinquent payments
- Followed up on missed payments and resolved financial discrepancies
- Examine patient bills for accuracy and request any missing information
- Assisted patients with payment plans
- Completed timely verifications of various insurances & benefits
- Pre-certifications and insurance verification for all patients
- Assisted patients with their hospital accounts
- Worked with LA Medicaid, completing applications for patients of all ages
- Corrects accounts online for faster processing; worked on self-pay accounts
HEDIS Specialist (Contract)
BCBS of IL
11.2021 - 08.2022
- Meeting and maintaining production and quality expectations for all assigned measures
- Knowledge of medical record abstraction, clinical reviews, and regulatory requirements
- Applied HEDIS concepts and principles in completing the abstraction and review process to ensure full recognition of delivered care for the member's benefit
- Used independent judgment to complete abstraction and review of medical records following program guidelines
- Transitions between priorities and abstraction projects based on program or client needs
- Perform daily tasks with acute diligence
- Assisted other team members at the manager's request
- Proficiency with PC
- Utilization of Microsoft Office applications
- Utilized medical terminology when necessary
- Utilized medical claims systems
Assistant Director
Lake Charles Memorial Hospital
01.2021 - 12.2021
- Assisted the director in executing team member training and development
- Created and managed team member assignments and schedules
- Communicated regularly with administration and other departments to set clear expectations and align goals
- Utilized HHS' electronic maintenance management system to track repairs, equipment installation, updates, and compliance checks
- Performed daily inspection rounds and provided coaching opportunities as needed
- Analyzed data and adjusted to meet facility goals, budget, and compliance requirements
- Managed vendor communications and ordering
- Implemented team-building initiatives to create a positive work environment
- Recruited quality team members who reflect HHS' values
- Hiring of new employees
- Trained new employees on administrative procedures
- Worked with various insurance companies, Cigna, United Healthcare, BCBS, and Aetna, to abstract medical records for HEDIS
- Worked collaboratively with office staff to maintain smooth operations and team readiness for unexpected demands
- Developed relationships with vendors, suppliers, and contractors
- Liaison with physicians and leadership to continue effective communication and strength
Providers- Management Administrative Support
Kelsey SEYBOLD
11.2019 - 01.2021
- Managed the General and Plastic Surgery front desk, which supported an estimated twenty providers; provided additional administrative support for the Gastroenterology department and staff
- Oversight for scheduling, insurance verification authorizations, charges/billing, claims reimbursement, and denial management via EPIC
- Worked with insurance companies, United Healthcare, BCBS, and Cigna to abstract medical records for HEDIS
- Calculated/collected patient's copays, deductibles, out-of-pocket maximums, coinsurance, and unmanageable debt balances
- Oversight for scheduling and patient flow
- Worked with Insurance companies, United Healthcare, BCBS, and Cigna, to assist patients with knowledge of insurance benefits, coverage, policies, and procedures
- Managed quality assurance program, including on-site evaluations, internal audits, and customer surveys
- Generated monthly statements to check outstanding balances
- The COVID-19 team is responsible for administering PCR test swabs, securing tested samples for delivery to laboratories, and conducting Rapid PCR swab testing
MEDICAL MANAGER
TSASC
10.2018 - 11.2019
- Managed the schedule for all company conference and meeting rooms, ensuring successful executive meetings
- Managed and coordinated activities of fifty-four staff and providers engaged in clerical and clinical service related to patient care
- Oversaw operation of customer service
- Scheduled and coordinated patient appointments and surgeries
- Recorded and updated personal and financial information via EPIC
- Worked with various insurance companies, Cigna, United Healthcare, BCBS, and Aetna, to abstract medical records for HEDIS
- Applied HEDIS concepts and principles in completing the abstraction and review process to ensure full recognition of delivered care for the member's benefit
- Used independent judgment to complete abstraction and review of medical records following the program
- Obtained and reviewed insurance authorization and referrals before patient services with treatment to maintain continuance of authorizations
- Worked collaboratively with office staff to maintain smooth operations and team readiness for unexpected demands
- Trained new employees on administrative procedures, injections, blood draws, vitals, and procedure room setup
medical Operations manager
Hagan HC Clinic
09.2009 - 10.2018
- Managed and coordinated activities with complete oversight of ten clinics and 60 staff members engaged in clerical and clinical service related to patient care
- Recorded and updated personal and financial information via EPIC
- Applied HEDIS concepts and principles in the completion of abstraction and review process to ensure full recognition of delivered care for the benefit of the member/patient
- Knowledge of medical record abstraction, clinical reviews, and regulatory requirements
- Medical record abstraction, clinical reviews, and regulatory requirements via Epic
- Worked with various insurance companies, Cigna, United Healthcare, BCBS, and Aetna, to abstract medical records for HEDIS
- Managed and coordinated administrative services such as expense management, payroll, performance evaluations, and employee reprimand
- Provided physician support while organizing operational procedures and assisted with coordinated scheduled appointments to optimize client satisfaction and facility efficiency via Epic
- Liaison with physicians and leadership to continue effective communication and strength
- Developed relationships with vendors, suppliers, and contractors
- Helped employees with day-to-day work and complex problems by applying motivational and analytical strategies
- Manage the schedule for all company conference and meeting rooms
- Trained new employees on the proper way to do injections and blood draws
- Entered daily charges, along with office deposits daily via Epic
Education
Remington College
03-2004
Skills
- Claims auditing
- ICD coding
- CPT coding
- Medical billing
- Policy analysis
- Denial management
- Data entry
- Customer service
- Detail orientation
- Effective communication
- Data interpretation
- Investigative skills
- Data verification
- Verbal communication
- Claims investigation
- Customer service and support
Timeline
Insurance Claims Auditor
SCS Inc.
07.2023 - 04.2024
Department Coordinator Finance
MHS
05.2022 - 10.2023
HEDIS Specialist (Contract)
BCBS of IL
11.2021 - 08.2022
Assistant Director
Lake Charles Memorial Hospital
01.2021 - 12.2021
Providers- Management Administrative Support
Kelsey SEYBOLD
11.2019 - 01.2021
MEDICAL MANAGER
TSASC
10.2018 - 11.2019
medical Operations manager
Hagan HC Clinic
09.2009 - 10.2018
Remington College
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