2. EDUCATION:
Winston-Salem State University
Bachelor of Science in Business Administration with a
concentration in Marketing, May 2007
Masters in Public Administration-currently pursuing
Relevant Skills and Experience
Detail oriented Judgment and Decision Making
Analytical Skills Critical Thinking
Communication skills Monitoring
Accounts Receivable Specialist –I investigate denials through
system resources and provider insurance websites in order to
have accurate information to bill private or government
insurance. Analytical skills are demonstrated by ability to find
trends and abnormalities in my environment
Eligibility Case Worker-determine eligibility for Medicaid
programs as well as to inform the client of their rights and
obligations as prescribed under program policies and explain
and interpret rules, policies, and procedures. The policies and
procedures were set forth by Department of Health and Human
Services. Important skills included negotiating, interviewing,
explaining information, gathering and compiling of data, analysis
of data. My duties also included managing, reviewing and
coordinating case files and adhering to confidentiality policies
set forth by agency compliance.
3. Importance of Policies and
Procedures
Policies and Procedures (P&Ps) provide
direction, guidance and oversight for Health
Center operations.
Public Safety and Security - Knowledge of
relevant equipment, policies, procedures, and
strategies to promote effective local, state, or
national security operations for the protection
of people, data, property, and institutions
4. Benefits of effective
Policies and Procedures
• The formulation of effective internal controls to assure compliance with
federal regulations, private payer polices and internal guidelines.
• Improved collaboration, communication and cooperation among healthcare
providers and those processing and using health information
• The ability to more quickly and accurately react to employees operation
compliance concerns and the capability to effectively target resources to
address those concerns
• A more efficient communication system that establishes a clear process and
structure for addressing compliance concerns quickly and effectively
• Procedures that allow the prompt thorough investigation of possible
misconduct by corporate officers, managers, employees and independent
contractor, who can impact billing decisions
• Early detection and reporting and enhancement of the structure of the billing
company’s operations and the consistency between separate business units.
5. Billing Compliance-Policies and
Procedures that govern healthcare
• Employees have a obligation to
maintain and protect confidentiality
of company and patient information
and documents.
• Federal and state prohibitions
against false and fraudulent claims
• Record Retention and destruction
• Payor Contracts
• Adjustments, writeoffs or credits
• Payment Information Policy
• Insurance Information Policy
• Processes for obtaining billing
information
• HIPPA Policy
-Reviews, assesses, studies, analyzes
the overall coding, billing,
documentation and
reimbursement system for
potential compliance problems
and non-compliant activities.
-Uses a systematic approach for the
identification and resolution of
complex compliance problems
-Maintain and analyze reports to
comply with various rules and
regulations.
-Conducts informal audits on various
aspects of the coding, billing,
documentation and reimbursement
system.
7. POLICIES and PROCEDURES
OBJECTIVES/ELEMENTS
• Written Policies and
Procedures
• Designation of a
Compliance Officer or
Business Service
Coordinator-billing
operations
• Conducting Effective
Training and Education
• Developing effective
lines of communication
• Enforcing standards
through well-publicized
disciplinary guidelines
• Auditing and
Monitoring
• Responding to detected
offenses and developing
corrective action
initiatives
8. Goals to have maintaining an
effective billing compliance
• Appropriate oversight
• Organized and effective training
• Documented billing policies and
procedures
• Continuous monitoring to prevent and
detect non-compliance
• Providing an avenue to investigate
employee compliance concerns
9.
10.
11. Examples or situations
• Campus Health Events
• Possible medication or
procedure error
• Quality of care issue
raised by patient
• Quality of care issue
raised by staff member
• Laboratory issue
• Dissatisfied or angry
patient
• Injury to
patients/visitors
(Fainting, fall, unsafe
situation)
• Patient care concern
(medication error,
incorrect
test/procedure, triage
disposition, delayed or
incorrect diagnosis)
• Laboratory safety issue
