Tori Branson
Delta,CO
Summary
Enthusiastic professional motivated to succeed in fast-paced and deadline-driven professional environment. Comprehensive knowledge of claims adjustments with special knowledge of PACE Organizations policies and procedures.
Overview
7
7
years of professional experience
Work History
Claims Adjudicator
Volunteers of America, Inc
Eden Prairie
09.2024 - Current
- Daily review and adjudication of a variety of claims.
- Researched contracts, policy language, relevant laws, and regulations to ensure accurate adjudication of claims.
- Advised management on potential areas of improvement in the system set up and claims processing.
- Utilized various software programs, databases, and other resources to obtain necessary information for claim processing.
- Communicated regularly with internal staff concerning changes in procedures or processes.
- Performed data entry into the claims system.
- Review and approve weekly prechecks as assigned.
- Create/maintain pend reports.
- Coordination within PACE organizations for any claim related items.
- Coordination with vendors/provides pertaining to claims.
- Coordination with claims system carrier to learn and enhance processing of claim system.
Claims Coordinator/Specialist
Volunteers of American
Eden Prairie, Minnesota
01.2021 - 09.2024
- Review, audit and maintained monthly IBNR for all PACE Organizations: Colorado, Michigan, North Carolina and Louisville Kentucky.
- Review and approval of weekly prechecks for all PACE Organization.
- Review and audit of weekly pend reports for all PACE Organization.
- Review and processing claim appeals for all PACE Organizations.
- Coordination with Peak TPA for claim processing and workflow.
- Coordination with providers/vendors regarding claims processing.
- Coordination within PACE Organization to create and maintain smooth workflow of claims to include: authorizations, reports, and enhancement.
- System administrator of Colorado EHR continued until 6/15/2023.
- Immense involvement of the Implementation of Peak TPA and Electronic Health systems for Louisville KY beginning 2/2023. EHR portion was transferred to another staff member as of 6/15/23. PACE Center opened 8/1/2023.
- PACE Locations: Michigan and North Carolina duties transferred to another staff member 1/2023.
- Training of new claims coordinator.
Compliance and Program Specialist
VOANS Senior Community Care Colorado
Eckert, Colorado
11.2020 - 01.2022
- Assisted in the creation and revision of program policies and procedures to ensure compliance.
- Reviewed all Colorado paper contracts, insurance, licenses to scan and organize into Global drive.
- Created process and audit reports for Medicare Part D. This included all PACE locations: Colorado, Michigan and North Carolina
- Review of Company Policy for updates or discrepancies of three way contract for Medicare (Federal Final Rule) & Medicaid (State Regulations) for Colorado, Michigan and North Carolina.
- System administrator for Colorado EHR (TruChart (medical) and Alayacare (home care)) continued during this role.
- Review, audit and maintained IBNR continued for all locations: Colorado, Michigan and North Carolina.
Medical Records Supervisor
VOANS Senior Community Care of Colorado
Eckert, Colorado
03.2019 - 11.2020
- Supervised staff responsible for the maintenance of patient records to ensure accuracy and compliance with HIPAA regulations.
- Ensured that all changes made to medical records are properly documented and authenticated by the appropriate personnel.
- Provided training sessions for staff on proper documentation techniques.
- Coordinated, maintained and updated electronic health records systems as system administrator.
- Also completed all duties listed in Medical Records position 4/2018-3/2019
Medical Records Specialist
VOANS Senior Community Care of Colorado
Eckert, Colorado
04.2018 - 03.2019
- Maintained accurate documentation of all activities related to medical records.
- Obtained, filed, scanned confidential patient documents into electronic health record system according to established procedures.
- Answered inquiries regarding the status of patient records or their availability.
- Collaborated with multiple departments and facilities to coordinate obtaining and the release of information requests from patients, providers and legal representatives within designated timeframes.
- Performed data entry for patient histories in accordance with established standards into electronic health records.
- Set up patient charts and documented information in various company software. Updating patient demographic as necessary.
- Scheduled appointments and updated calendars for medical staff based on patient records.
- Provided training on the use of electronic health records system to staff members.
- Assisted in auditing medical records for compliance with legal and regulatory standards.
- Review, audit and maintained IBNR.
Skills
- Detail oriented
- Analytical & organizational abilities
- Effective communication
- Commitment to accuracy & quality
Timeline
Claims Adjudicator
Volunteers of America, Inc
09.2024 - Current
Claims Coordinator/Specialist
Volunteers of American
01.2021 - 09.2024
Compliance and Program Specialist
VOANS Senior Community Care Colorado
11.2020 - 01.2022
Medical Records Supervisor
VOANS Senior Community Care of Colorado
03.2019 - 11.2020
Medical Records Specialist
VOANS Senior Community Care of Colorado
04.2018 - 03.2019