Francesca OConnor
Palmdale
Summary
Driven Benefit Claims Specialist with over 25 years of Medicaid/Medicare claims for provider payments, paying close attention to details to avoid over and underpayments. Maintains production and claims quality of standards. Communicates with management regarding issues or trends in claims that could be considered fraud. Proofs claims for appropriate claim information regarding coding, member identification, diagnosis, services and correct provider information. Reviews Pharmacy/Medial claims in accordance with Medicare and Medicaid guidelines. Reviews eligibility and investigates benefits in accordance with Medical claim processing guidelines followed by adjudicating claim once everything has been verified. During my years with the company my skill includes scheduled appointments and travel arrangements for the director and Managers, setting up interviews, processing help desk tickets for the analysts to make repairs for the health plans. Back billed and processed payment for individual providers to balance books for the year. Prepared purchase order requests for the DPS department cell phones, ran daily, monthly and year-end reports. Experience offering personalized, courteous service.
Overview
19
19
years of professional experience
Work History
Billing Specialist
Community Care Partners
06.2022 - Current
- Researched and resolved billing discrepancies to enable accurate billing.
- Monitored customer accounts to identify and rectify billing issues.
- Provided excellent customer service, developing and maintaining client relationships.
- Worked effectively with medical payers such as Medicare, Medicaid, commercial insurances to obtain timely and accurate payments.
- Prepared and submitted monthly billing reports to management for financial overview.
- Identified payment trends and adjusted billing processes accordingly to retain customers.
- Handled day-to-day accounting processes to drive financial accuracy.
- Epic Systems Healthcare Software
Claims Benefit Specialist
Aetna
06.2019 - 01.2024
- Coordinated with contracting department to resolve payer issues.
- Reviewed outstanding requests and redirected workloads to complete projects on time.
- Communicated effectively with staff, including members of operations, finance and clinical departments.
- Acted as subject matter expert, answering internal and external questions and inquiries.
- Devoted special emphasis to punctuality and worked to maintain outstanding attendance record, consistently arriving to work ready to start immediately.
- Applied medical necessity guidelines; determines coverage; verified eligibility; identified discrepancies; and applied all cost containment measures to assist in claim adjudication processes.
- Performed claims re-work calculations.
- Identified and reported possible claims overpayments, underpayments, and irregularities.
- Ensured compliance requirements were met.
- Ensured payments were made in accordance with company practices and procedures.
- Reviews pre-specified claims or claims which exceed specialist adjudication authority or processing expertise.
- Ensures compliance requirements are satisfied, and payments are made in compliance with company practices and procedures.
- Re-works claim payments.
- Determines medical necessity and coverage as per guidelines; verifies eligibility; identifies discrepancies, and applies all cost containment measures to assist in claim adjudication processes.
- Manages and monitors daily workflow and reporting to ensure business objectives are maintained and accurately reported; ensures resources are aligned appropriately across function and/or service center.
- Follows a pattern of operations generally standardized, but frequently includes rules, expectations, and special instructions, which demand close attention to process claims.
- Follows strict federal guidelines and state mandates to make determinations on claims.
Accounts Receivable Supervisor
Lafayette General Medical Center
02.2018 - 05.2022
- Experience in Epic Solutions Software systems.
- Improved cash flow by implementing efficient accounts receivable processes and reducing outstanding balances.
- Enhanced team productivity by providing regular training on accounting software and tools.
- Streamlined account reconciliation procedures, ensuring timely and accurate financial reporting.
- Collaborated with internal departments to resolve billing discrepancies, improving interdepartmental communication.
- Managed hundreds accounts worth $24 million (monthly) while supervising team of 8 clerks and 6 lower-level accounts.
- Set goals for accounts receivable team of 8 clerks and developed strategies to meet goals.
- Hired, managed, developed and trained staff, established and monitored goals, conducted performance reviews and administered salaries for staff.
- Delegated tasks to administrative support staff to organize and improve office efficiency. Implemented project management techniques to overcome obstacles and increase team productivity.
- Built highly-efficient administrative team through ongoing coaching and professional development opportunities.
- Optimized organizational systems for payment collections, AP/AR, deposits, and recordkeeping.
Reimbursement Specialist
Tides Medical
01.2016 - 12.2018
- Completes accurate and timely insurance verification.
- Completes accurate and timely third party payer authorization requests, including ensuring all necessary data elements needed for an authorization (e.g., CPT codes, diagnosis codes) are available.
- Ensures services scheduled by outside providers have approved authorization as required by payer and procedure prior to service.
- Communicates with patients, insurers, and other appropriate parties pertaining to insurance verification and authorization.
- Trained in Epic Systems software
- Provides clear documents for financial clearance work according to Standard Documentation Guidelines.
- Maintains productivity and quality performance expectations.
- Reviews and meets ongoing competency requirements of the role to maintain the skills, knowledge, and abilities to perform, within scope, role specific functions.
Team Lead/Insurance Billing Specialist
Acadiana Computer Systems
05.2005 - 12.2015
- Improved team productivity by implementing efficient project management strategies and streamlining communication channels.
- Enhanced overall team performance by providing regular coaching, feedback, and skill development opportunities.
- Led cross-functional teams for successful project execution while maintaining strong collaboration among team members.
- Increased customer satisfaction by ensuring timely completion of projects and adherence to high-quality standards.
- Worked effectively with medical payers such as Medicare, Medicaid, commercial insurances to obtain timely and accurate payments
- Identified, researched, and resolved billing variances to maintain system accuracy and currency.
Education
BBA - Business Administration And Management
University of Louisiana At Lafayette
Lafayette, LA07.2024
Associate of Arts - General Studies
South Louisiana Community College
Lafayette, LA05.2022
Skills
- Excellent Team Leadership
- Billing Management
- Revenue Cycle Management
- Accounts Payable and Accounts Receivable
- HIPAA Regulations Billing Cycle Performance
- Experience in Epic Systems, Cerner Software System
- Account Resolutions Account Analysis Expertise
- Collections
- Claims Processing
- Payment posting
- Insurance Policies Understanding
- Appeals Process Proficiency
Timeline
Billing Specialist
Community Care Partners
06.2022 - Current
Claims Benefit Specialist
Aetna
06.2019 - 01.2024
Accounts Receivable Supervisor
Lafayette General Medical Center
02.2018 - 05.2022
Reimbursement Specialist
Tides Medical
01.2016 - 12.2018
Team Lead/Insurance Billing Specialist
Acadiana Computer Systems
05.2005 - 12.2015
BBA - Business Administration And Management
University of Louisiana At Lafayette
Associate of Arts - General Studies
South Louisiana Community College
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