Wendy Kirk

• Collaborate with Wellvana’s Director of Clinical Operations to utilize corporate resources effectively, driving achievement of Pay Performance Indicators (KPIs) at both practice and market levels
• Provide education and guidance on Value-Based Care clinical programs, ensuring healthcare providers are equipped to deliver high-quality, cost-effective patient care aligned with industry standards and regulatory requirements
• Review coding, claims utilization, clinical, revenue cycle, and quality data
• Effectively communicate, build, and execute improvement plans at the practice level, based on areas of opportunity identified
• Provide coding clinics to practices, to help improve their Risk Adjustment Factor (RAF) score
• Develop and implement workflow designs, including optimizing electronic health records (EHR), clinical documentation, billing practices, assessments, financial analyses, and reporting for financial performance improvement.
• Facilitate patient follow-up after unplanned admissions and ED visits through coaching of providers and their staff
• Collaborate with providers and their staff to improve continuity of care and streamline an intervention process
• Actively participated in cross-functional teams to conduct work and resolve enterprise and regional issues
• Performed other job duties as assigned.

• Facilitated daily operations of the medical office, which included managing the staff, office accounts, and other administrative tasks

Kept up-to-date with insurance policies and guidelines

• Managed office finances, including billing, budgeting, payroll, and purchasing supplies
• Ensured that all insurance and patient payments were posted daily and reconciled by the end of each workday
• Provided necessary training to employees and conducted HIPAA training annually
• Handled workers' compensation and auto claims accounts, obtained proper documentation from patients to ensure correct claims payments, followed up with attorneys or insurance companies to negotiate payment of claims, and posted all payments to the correct accounts
• Reviewed medical claims for submission to the clearinghouse, updated coding errors, and revised any coding inconsistencies
• At the end of each week, claims were batched, reviewed, and scrubbed
• Clean claims were then electronically filed to the insurance companies, attorneys' offices, or auto insurance companies
• Conducted meticulous HEDIS reviews for coding accuracy and care gap detection
• Each month, Medicare and Medicaid claims were reviewed for HCC accuracy, ensuring that each medical record was consistent with what was coded
• Best coding practices resulted in higher financial gain for the practice
• Streamlined the patient check-in process by verifying patient insurance 24 hours before the appointment to ensure the insurance was active, determine co-pays due, and check for patient deductibles
• Maintained insurance portals, EMR, and clearinghouse, ensuring that payments for all 835 files were always up to date.

• Led efficient staff meetings to boost productivity
• Each meeting included the financial analysis of accounts receivable and denials, and a collaborative effort was made to reduce denials and increase accounts receivables
• These meetings resulted in fewer denials and more revenue
• Followed up promptly on difficult claims to ensure prompt reimbursement
• Reviewed and evaluated cost reports for daily financial verification and comparison
• Credentialed new insurance companies, maintained contracts, and negotiated insurance contracts
• Conducted interviews, hired staff, conducted performance reviews, and maintained Financial/insurance Portals

• Extracted patient data from EMR systems for verification, accuracy, and analysis
• Data extracted is utilized in the medical record review process
• Medical reviews for HEDIS scoring are reviewed for accuracy, medical documentation, and hierarchical coding
• Reviewed patient diagnoses to ensure alignment with provider's documentation in medical record
• Addressed concerns and questions by consulting with providers for updates or confirmation
• Established positive and consultative relationships with Facilities, Physicians, and Nursing homes
• Identify performance gaps, quality measures, and root causes
• Communicated review findings and HEDIS score findings to Physicians and approved medical personnel

• Managed customer data and processed pension applications and annuity payments by calculating pension payments, insurance payments, and contractual adjustments
• Organized and managed assignments by creating and updating data in Excel spreadsheets
• Provided customer service to members by addressing questions and concerns via letter, email, and/or phone
• Used accounts payable/receivable for processing annuity payments, pension payments, processing insurance client payments, and refunds
• Corresponded with vendors/clients and responded to inquiries regarding pensions
• Documented all accounts payable transactions as needed
• Prepared monthly and daily reports; all patient reports were added to patients accounts

• Verified provider and facility documentation submitted for network approval
• Review PECOS, CAQH, State licensing, and background network for provider and facility profiles
• Negotiate contracts if needed and ensure validity of all information provided before providing an approval or denial
• Approved providers and facilities were entered into the provider platform, and added to networks of choice
• Fee schedules were added to accounts and contracts were reviewed for errors and omissions before being finalized
• Final contracts were mailed to providers/facilities
• Denial letters were mailed as needed
• Corresponded with physicians, nursing homes, and hospital directors in writing and by phone communicating important network information