Ronni Rishwain
Stockton
Summary
Experienced professional dedicated to utilizing extensive knowledge and expertise to make critical decisions that positively impact the company. Strong focus on claim adjudication and auditing. Successfully managed a team of 15 individuals, providing comprehensive training and guidance. Achieved professional goals while ensuring strict compliance with all guidelines.
Overview
31
31
years of professional experience
1
1
Certification
Work History
Medical Billing Specialist
American Medical Associates
07.2022 - 11.2024
- Billed CAH hospitals (Acute, Swing and Skilled Nursing claims) Followed all CAH guidelines for timely and accurate submissions
- Billed Various payors: Commercial, BCBS, Healthnet, Kaiser various HMO, PPO, etc
- Medicare, Medi-cal and Federal plans
- Followed up on all electronic submissions, corrected claims, and Appeals
- Posted payments added and deducted charges on accounts per Contracts, R&C and Fee schedule
- Completed all secondary COB billing
- Reviewed all coding for accuracy
Senior Claims Auditor
Kaiser Permanente
06.2013 - 05.2022
- Responsible for auditing the accuracy of all processed claims based on a comprehensive knowledge of benefit package, utilization guidelines and appropriate division of financial responsibility
- Review Claim Denial letters
- To manage all Deficiencies, complete remediation steps and evidence
- Complete and assist testing for Tapestry, SOMA, EDI, File, Contracts, and system enhancements
- Complete DMHC, Sox Audits
- Complete remediation steps and action plans
- Run the Inventory management reports, distribute work to all auditors
- Accountable for tracking and/or monitor results to senior management
- Conduct root cause analysis for claim payment and accuracy
- Coaching the Auditors for Production and Tapestry
- Complete SLR calls on a weekly basis
- Work on Root Cause and system enhancements
NCal Continuum Claims Manager
Kaiser Permanente
01.2010 - 06.2013
- Manage 13 employees oversee claim processing, for the Continuum (SNF, DME, and Home Health/Hospice), developed policy's from start to finish
- Maintain payroll, and physician checks
- Leading status meetings with vendors, peers, etc
- Oversee all claims processing for SNF, DME, HH, and Hospice
- Prepare and enhance Quality and Compliance audits on a monthly basis
- Prepare and analyze for Sox for internal and external audits
- Supervise the OPA Audits
- Review all claims for Coordination of Benefits, TPL, WC, and Medicare Primacy
- To manage all Deficiencies, complete the remediation steps and evidence
- Completed Time and all adjustments for the Union Staff
- Completed Payroll on a bi-weekly basis
- Updated HEAR's when appropriate for staff Completed testing for SOMA, EDI, File Contracts, and system enhancements
Lead Medical Bill Examiner
Kaiser Permanente
01.2008 - 12.2010
- To ensure all Outside Medical Services Claims and Continuum Claims, are reviewed and audited for a correct prepayment basis, Contract Accuracy, Medicare, and Medi-cal rates
- Verify Anesthesia rates, and modifiers, claim Adjudication, Compliance, Customer Service
- Run and track production, and inventory Control
- Run the Month End reports for inventory and production
- Complete the VAR (opt-out Medicare providers)
- Ensure all Federal and State Regulations are followed: SOX, CMS, and DMHC
- Work with the Internal Auditors, and Managers to review Audit findings
- To manage all Deficiencies, complete remediation steps and evidence
- Supervise team of four
Facility Referral Coordinator
Kaiser Permanente
01.2002 - 12.2008
- Processed all Skilled Nursing, Ambulance, Home Health/Hospice, and Home Health Claims for Stockton, Modesto, and Fresno
- Monitored monthly budget for all services, Followed all guidelines, compliance
Senior Coordinator of Benefits Analyst - Lifeguard
Lifeguard insurance
01.1999 - 12.2002
- Supervised Membership department
- Maintained multiple queues, eGain, and report analysis
- Worked with various departments such as Recovery and Savings, Legal, Customer Service, as well as claims and Provider Services in the coordinating of benefits for members
- Worked with Medicare to assist with Medicare COB rules/secondary payor
- Reviewed and supervised ED claim submissions
Senior Customer Service Representative
Blue Shield of California
01.1994 - 12.1999
- Handled all customer service calls coming into the various queues
- HMO, PPO, POS, and Pers Accounts
- Supervised member appeals, and provider appeals
- Worked closely with the Medical Review department to satisfy all customer service goals
- Adjusted claims, for professional and facility
- Coached Customer Service staff to make our goal of 100% customer satisfaction
Education
Life Insurance License - Life Insurance
PST
Sacramento 05.2024
High school diploma or GED - Business
Marian A Peterson High School
Sunnyvale, CA05.1978
Skills
- Anatomy Knowledge
- Accounting
- Medical Terminology
- Medical Office Experience
- EMR Systems Epic
- Cicspro
- Allscripts
- Cerner
- Eclinical
- Microsoft Excel
- Typing
- Insurance Verification
- Medical Billing
- Medical Records
- Writing skills
- Medical Scheduling
- Auditing
- Data entry
- Medical Collection
- ICD-10
- Internal Audits
- ICD Coding
- CPT Coding
- Process Improvement
- Microsoft SharePoint
- Microsoft Office
- Quality Assurance
- Accounts Receivable
- Root Cause Analysis
- SOX
- EDI
- HIPAA
- Customer service
Certification
Life Insurance License
Personal Information
Authorized To Work: US
Timeline
Medical Billing Specialist
American Medical Associates
07.2022 - 11.2024
Senior Claims Auditor
Kaiser Permanente
06.2013 - 05.2022
NCal Continuum Claims Manager
Kaiser Permanente
01.2010 - 06.2013
Lead Medical Bill Examiner
Kaiser Permanente
01.2008 - 12.2010
Facility Referral Coordinator
Kaiser Permanente
01.2002 - 12.2008
Senior Coordinator of Benefits Analyst - Lifeguard
Lifeguard insurance
01.1999 - 12.2002
Senior Customer Service Representative
Blue Shield of California
01.1994 - 12.1999
Life Insurance License - Life Insurance
PST
High school diploma or GED - Business
Marian A Peterson High School
Similar Profiles
Yamina SantiagoYamina Santiago
Assistant Manager at Patient Care Associates | American Care Medical CentersAssistant Manager at Patient Care Associates | American Care Medical Centers
Nereyda ZacariasNereyda Zacarias
Patient Care Technician at Davita Inc. & American Renal AssociatesPatient Care Technician at Davita Inc. & American Renal Associates
Ashlee DoveAshlee Dove
Senior Security Officer at American Security AssociatesSenior Security Officer at American Security Associates