Priscila Solange Fernandez

• Reviewed member claims for accuracy and compliance with company policies.
• Analyzed data to identify trends in healthcare services utilization.

• Answer providers and facilities calls.

• Analyze claims, denials and payments.

• Provide full detailed explanation of payments.

• Locate/attach medical records.

•Verify level of payment, down graded codes and DRG codes.

• Review eligibility, hospice status, COB.

• Validate authorizations and supporting documentation.

• Confirmed timely filing submission.

• DOFR verification and clarifying contracts details and W9.

• Manually entering claims into system.

• Provide appeals status for contract and non-contracted providers.

• Performing check tracers, void and reissue payments.

• Review faxes, and incoming mail.

• Responds to provider e-mails and voicemails.

• Collect money due from insurance companies, hospital and patients in compliance with CLIA, OIG and all other applicable legal requirements.
• Contact insurance companies to follow up on claims and appeals which have been submitted, but no payment or correspondence received within the allotted time frame.
• Process and follows up with patients for copays and deductible amounts due.
• Contact clients to obtain medical records as needed for submission of a medical appeal or payer's review of a claim.
• Prepare custom appeal letters and letters of interest to various insurance carriers and managed care groups.
• Review files to determine if amounts should be written off based on acceptable reimbursement, then forwards these to the Reimbursement Manager.
• Investigate and prepares any necessary refund requests from payors for submission to the Reimbursement Manager.
• Negotiate reimbursement single settlements with various insurance carriers and third party administrators, based upon department guidelines.
• Interface with insurance company representatives, doctor's offices and hospitals regarding schedule of services and billing inquiries.
• Assist department director in the development of new procedures and systems to enhance productivity.
• Provide account information to the sales force as needed.

• Creating billing summaries for each month's billed units and total amount charged.
• Calculate service times starting in 15 minute increments into billable units.
• Verify client treatments, consents, Cal-OMS, authorization and attachments.
• Residential facility/outpatient facility component.
• Track progress note's units per service.DRAFT
• Verify case managements, assessment, miscellaneous note, groups sessions, individual sessions.
• Creating beneficiary accounts on excel and verify personal information.
• Meeting each month's billing cycle in a timely manner.
• Maintain compliance with FDCPA and HIPAA requirements.
• Ability to work in a fast-paced environment; can multi-task and work independently as well as with a team.

• Checking eligibility, obtaining authorizations/retro authorizations from insurances.
• Submitting claims, appealing claims, adjusting claims, review EOBs, payment posting.
• Access denied claims from the work list and queries claim status with the payor, utilizing all appropriate systems, websites to effectively research claim and resubmit or appeal as necessary.
• Answering incoming calls from customer regarding: date of services/co-pays/ co-insurance.
• Assisting customers with credit cards payment over the phone.
• Outgoing calls to collect past due payments.
• As requested by insurance companies to ensure timely resolution of outstanding denied/unpaid claims.
• Understanding insurance guidelines from HMO, PPO, Medical and Medicare.
• Responsible for obtaining payment of claims.
• Investigate insurance denials and identify issues then take best action to get claim paid.
• Outpatient/inpatient, ambulatory facility component, surgical center, pathology, professional office and anesthesia.
• Systems: Office Ally, MD systems, Provation, GMed, Payspan and Health care portals.
• Mailing out billing statements to customers and health insurances.
• Aid in working on unresolved patient accounts to determine the appropriate action necessary to resolve open balances.
• Consistently follow up on unpaid, under paid and denied claims utilizing monthly aging reports, filing appeals and establish/maintain strong relationships with providers, clients and fellow staff.

• Assisting customers with technical issues/ troubleshoot.
• Data Entry, inputting customer's information into the states database.
• Reviewing/Peer Review documentation before inputting information into database.
• Provide customers with quotes over the phone.
• Submitting applications into Edison's portal.
• Calculate/verify customer's gross income.
• Submitting customer's proof of income and residency.
• Updating personal information in customer's account.
• Operate a PC, relevant applications / software, telephone, fax and copier.