DENISE WARD
Concord
Summary
Certified Professional Medical Coder (CPC) with expertise in coding, billing, and appeals. Proficient in E&M, ICD, CPT, and HCPCS coding. Skilled in analyzing complex claims, appealing denials, and ensuring compliance with CMS guidelines. Experienced in managing high volumes of claims, maintaining coding accuracy, and resolving billing issues efficiently. Strong problem-solving skills and attention to detail with a focus on optimal reimbursement and exceptional customer service.
Skilled claims processing professional with extensive experience in reviewing and validating insurance claims. Strong focus on accuracy, problem-solving, and effective communication. Known for a collaborative approach and adaptability to changing needs. Proficient in claims software, data entry, and customer service. Recognized for reliability and achieving results in team environments.
Overview
14
14
years of professional experience
Work History
Claims Processor Medical Billing
IQVIA
07.2023 - 03.2025
- Managed a high volume of claims, 50 daily, prioritizing tasks in CSS to meet deadlines without sacrificing quality.
- Reviewed and analyzed all Pfizer claims to ensure accuracy, completeness, and compliance with company policies.
- Maintained strict confidentiality when dealing with sensitive information about patients' medical histories or personal details.
- Identified fraudulent claims through thorough investigation and documentation of findings. Making sure the NPIs matched the physician maintenance in CSS, checking NDCs, making sure they are in CSS, and determining if they are payable. If NDCs aren't in the system, they will be denied.
- if new claims where done then id work on rejected claims, Seeing if documents where uploaded to a claim and if not it would remain rejected and if it was over 180 day period it would be rejected for timely filing.
MEDICAL CODER/APPEALS PROVIDER Contract
Blue cross blue shield of North Carolina
11.2021 - 06.2023
- Analyzed and resolved complex claim denials, ensuring accurate coverage and reimbursement, enhancing compliance with CMS and coding guidelines
- Updated policies based on federal legislative changes, improving reimbursement efficiencies, and aligning with evolving coding and reimbursement standards
- Interpreted provider and health plan contracts, securing accurate claim payments and reducing service denials by adhering to contract terms
- Provided feedback to corporate and facility teams on clinical appeals, improving processes and outcomes through actionable insights
- Maintained quarterly physician and hospital reports, ensuring accurate and up-to-date information for effective claim management
- Supported the Appeal Letter Training Program, enhancing regional managers' and medical directors' appeal processes and outcomes
- Conducted authorization audits on denials and appeal documentation, delivering training suggestions that improved accuracy and compliance
- Reported and analyzed appeal and denial issues, identifying trends that optimized the authorization process and boosted collections
- Acted as a resource for verifiers on documentation and coding, streamlining clinical account reviews, and improving claim accuracy
- Tracked appeals to provide management with timely updates, facilitating informed decisions, and efficient resolution of issues
- Utilized resources like Facets and Optum Maces, applying updates to appeals processes, enhancing documentation accuracy, and appeal success
- Increased coding accuracy by diligently reviewing medical documentation and applying appropriate codes.
- Resourcefully used various coding books, procedure manuals, and on-line encoders.
APPEALS ANALYST / MEDICAL CODE Contract
GDIT CDC
09.2019 - 09.2021
- Processed 475+ accounts daily, ensuring high accuracy and efficiency in claim adjudication
- Maintained MedDRA coding standards, enhancing compliance and accuracy in medical coding
- Conducted quality assurance of MedDRA Term Selection documents, improving coding reliability and consistency
- Verified eligibility and applied medical necessity guidelines, enhancing accuracy and resolving discrepancies in claim adjudication
- Coordinated responses for routine inquiries and grievances, improving claim processing, and customer satisfaction
- Utilized ICD-10/9 coding expertise and knowledge of insurance types to enhance claim accuracy and coverage determination
- Managed computerized billing and registration procedures, resolving issues effectively and streamlining financial operations
- Applied electronic health record systems (Epic, Cerner, Meditech), improving data management and patient record accuracy
- Handled high call volumes and conducted surveys, enhancing customer service and decision-making support
- Implemented NCQA's HEDIS measures, achieving an 80% improvement in care gaps through targeted analytic reports
- Championed continuous improvement initiatives within the appeals department, implementing process enhancements that led to increased efficiency and productivity.
- Utilized guidelines and review tools to conduct extensive research and analyze grievance and appeal issues.
MEDICAL CODER AND COLLECTION SPECIALIST/APPLIES CO
DYNAMIC HEALTH MEDICAL GROUP
01.2011 - 07.2019
- Ensured 100% file accuracy while maintaining patient confidentiality and information security
- Streamlined AR billing, enhancing revenue recovery, and reducing errors
- Efficiently managed batch and billing tasks, improving financial operations
- Processed physical therapy and rehab billing, accelerating claim accuracy and reimbursements
- Verified IVF insurance coverage, ensuring accurate eligibility and benefits information
- Organized scans and filings, enhancing document retrieval efficiency
- Credentialed providers, simplifying onboarding and compliance
- Applied HCC coding for chronic diseases, improving risk adjustment accuracy
- Analyzed inquiries and complaints, crafting effective appeal letters to resolve issues
- Obtained and distributed medical records, supporting accurate claims, and timely information sharing
- Assigned correct ICD-10/9 codes, ensuring accurate diagnosis documentation
- Utilized HCPCS and CPT codes accurately, enhancing billing and reimbursement
- Co-chaired the Grievance and Appeals Committee, improving case reviews, and representing HPSM in hearings
- Processed appeals and grievances per plan specifics, ensuring fair resolutions
- Explained the appeals process to clients, facilitating smoother resolutions
- Increased coding accuracy by diligently reviewing medical documentation and applying appropriate codes.
- Resourcefully used various coding books, procedure manuals, and on-line encoders.
Education
Bachelor of Science -
Full Sail University
Winter Park, FL11-2026
Medical Billing And Coding -
Central Piedmont Community College
01.2020
High School Diploma -
DutchFork High School
06-2008
Skills
- Detail-Oriented
- Analytical
- Problem-Solver
- Organized
- Adaptable
- Communicative
- Resourceful
- Collaborative
- Ethical
- Customer-Focused
- Proactive
- Strategic Thinker
- Tech-Savvy
- Empathetic
- Time-Management
- Creative Thinker
- Results-Driven
- Focused
- Conflict Resolver
- Efficient
- Critical Thinker
- Decision-Maker
- Team Player
- Interpersonal Skills
- Negotiator
- Self-Motivated
- Attention to Detail
- Stress Resilient
- Innovative
- Flexible
- Claims review
- Accuracy and precision
- Transactions reconciliation
- Claims
- Claims processing software
Languages
English
Full Professional
Spanish
Elementary
Timeline
Claims Processor Medical Billing
IQVIA
07.2023 - 03.2025
MEDICAL CODER/APPEALS PROVIDER Contract
Blue cross blue shield of North Carolina
11.2021 - 06.2023
APPEALS ANALYST / MEDICAL CODE Contract
GDIT CDC
09.2019 - 09.2021
MEDICAL CODER AND COLLECTION SPECIALIST/APPLIES CO
DYNAMIC HEALTH MEDICAL GROUP
01.2011 - 07.2019
Bachelor of Science -
Full Sail University
Medical Billing And Coding -
Central Piedmont Community College
High School Diploma -
DutchFork High School
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