Giselle Nieto
Manteca
Summary
Experienced Medical Billing and Collections Specialist with expertise in coding, claims processing, and insurance coordination. Proficient in HIPAA compliance and customer support, with a strong background in Medicare and Medicaid billing. Seeking to leverage skills to optimize billing processes and support healthcare operations effectively.
Overview
6
6
years of professional experience
Work History
Medical Billing and Collections Specialist
Howard Orthopedics
Richmond
04.2019 - 10.2023
- Review EOBs and collect accurate co-payments and co-insurance
- Obtain proper insurance authorizations for medically necessary services; and coordinate care as appropriate
- Compose medical necessity letters for compliance and proper reimbursement
- Ensure accuracy of HCFA1500 claim forms for EDI billing, including proper ICD10/CPT coding
- File appeals, redeterminations as appropriate for contractual reimbursement
- Years of experience working with the Medicare and Medicaid population
- Extensive experience working with Medicare, Medicaid, Medicare Advantage Plans, and Commercial Plans
Prior Authorization Nurse
Optimum Healthcare IT
Jacksonville
11.2018 - 04.2019
- Company Overview:
- Conduct review of authorization requests for selected specialties, medical treatments and services
- Using MCG guidelines to make clinical decisions based on established criteria and regulatory requirements
- Using the IPA guidelines to establish medical necessity for requested medical services, and procedures
- Prior Authorization RN Manages the utilization of membership, conducts chart review for medical appropriateness of behavioral health services
- Ensures that quality care is delivered in a cost-effective, timely manner
- As a Prior Authorization Nurse work in coordination with an interdisciplinary team to achieve the organization goals as well as department specific goals and objectives.
RN Complex Case Manager
Blue Shield of California
Rancho Cordova
01.2018 - 04.2018
- Support Partnership Health Plan's efforts in providing accurate HEDIS data to NCQA
- HEDIS Nurse Reviewer is responsible for reviewing medical records that have been abstracted
- This position is accountable for reviewing a large volume of medical records within a limited time frame
- Review and abstract from medical records (in both electronic medical record systems and/or paper charts) to support reporting of HEDIS measures
- Perform accurate and comprehensive reviews of medical records timely, while maintaining appropriate HIPAA privacy and security standards
- Identify the medical information that supports the specific HEDIS measure specifications
- Enter extracted data into designated software system
- Work with the Quality Improvement HEDIS team to identify and share best practices and opportunities for improvement
- Participate in medical record inter-rater activities as required
- Report daily on Medical Record Review productivity
- Attend and participate during HEDIS team meetings
- Occasionally may need to conduct review at provider offices on an as-needed basis
- Experience with Electronic Medical Records.
Education
Associate of Science - Nursing Practice
Maurine Church Coburn School of Nursing
Monterey, CA06-1998
Skills
- HIPAA compliance
- Continuous learning mindset
- Claims processing proficiency
- Professionalism and ethics
- Claims processing
- Prior authorization
- Reimbursement strategies
- EDI billing
- Healthcare compliance
- Customer relationship management
- Billing software proficiency
- Population health management
- Medical record review
- Attention to detail
- Time management
- Effective communication
- Problem solving
- Team collaboration
- Medical coding expertise
- Payment posting accuracy
- Accounts receivable management
- Medical billing software proficiency
- Patient billing assistance
- Denial resolution
- ICD-10
- Collections strategies
- Insurance verification
- Data entry efficiency
- Medical terminology mastery
- Conflict resolution
- Electronic health records experience
- Strong negotiation skills
- Goal-oriented mindset
- Assertiveness
- Stress tolerance
- Medical billing
- Debt recovery expertise
- Data entry proficiency
- Payment transactions
- Reporting skills
- Reliability
- A/P and A/R expertise
- Tax preparation
- Account posting
- Auditing proficiency
- Documentation skills
- Revenue forecasting
- Financial statement preparation
- Collections processing
- Excellent communication
- Professional demeanor
- Professionalism
- Mathematical skills
- Inquiry handling
- Administrative support
- Billing statement management
- Professional communication
- Regulatory filings
- Regulatory compliance
- Goal setting
- Purchase orders
- Postage determination
- Billing statement review
- General ledger management
- Account collections
- Computer literacy
- Job billing
- Market value estimation
- Billing document creation
- Teamwork and collaboration
- Payment collection
- Bill payment
Languages
Spanish, Fluent
Timeline
Medical Billing and Collections Specialist
Howard Orthopedics
04.2019 - 10.2023
Prior Authorization Nurse
Optimum Healthcare IT
11.2018 - 04.2019
RN Complex Case Manager
Blue Shield of California
01.2018 - 04.2018
Associate of Science - Nursing Practice
Maurine Church Coburn School of Nursing
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