Tiffany Wilson
Jamestown
Summary
With a proven track record at Acclara/R1 RCM, I excel in insurance claims processing and possess advanced Microsoft Excel skills. My professionalism and effective communication have consistently enhanced account follow-up processes, achieving significant insurance reimbursements. An adept multitasker, I thrive in fast-paced environments, ensuring meticulous attention to detail and compliance. Seasoned Insurance Reimbursement Specialist with robust experience in handling insurance claims and reimbursement issues. Bring forth strong understanding of insurance policies, coding, billing, and healthcare regulations. Skilled in analyzing claim denials, correcting errors, and liaising with insurance companies to ensure maximum reimbursement. Previous work has resulted in improved efficiency and accuracy in processing claims and securing timely payments for services rendered.
Overview
23
23
years of professional experience
3
3
years of post-secondary education
1
1
Certification
Work History
Accounts Receivable Analyst
National America Partners in Anesthesia
Raleigh
03.2025 - Current
- Managed follow up and resolution of outstanding anesthesia and pain management insurance claims to ensure timely reimbursement and reduced aging accounts receivable.
- Utilized Athenahealth/AthenaIDX billing systems to perform insurance follow up, account review, claim research, and documentation updates.
- Worked assigned accounts from WorkQ and management generated spreadsheets to prioritize follow up efforts and meet productivity goals.
- Worked prepaid and audit accounts to identify billing discrepancies, resolve account issues, and ensure accurate claim reimbursement and account reconciliation.
- Worked Anthem Blue Cross Blue Shield, Medicare, Medicaid, and other commercial payer accounts to resolve denied, rejected, and underpaid claims.
- Utilized insurance payer portals and online systems to verify claim status, eligibility, benefits, authorization requirements, and payment information.
- Reviewed and analyzed payer denials related to medical necessity, authorization, bundling, duplicate claims, modifier usage, eligibility, and coordination of benefits.
- Submitted appeals, reconsiderations, corrected claims, and supporting documentation to obtain claim resolution and maximize reimbursement.
- Used payer portals including Availity and Medicare portals to verify claim status, benefits, eligibility, MSP information, and payment details.
- Communicated directly with insurance representatives regarding claim status, reimbursement discrepancies, appeals, and payer policy requirements.
- Processed corrected and replacement claims for billing errors, modifier corrections, provider updates, and payer specific requirements.
- Collaborated with coding, payment posting, provider enrollment, charge correction, and revenue optimization teams to resolve complex account issues.
- Monitored accounts receivable aging reports and prioritized high dollar and timely filing accounts to improve collections and reduce outstanding AR balances.
- Maintained detailed documentation of account activity, payer communication, claim actions, and follow up efforts within the billing system.
- Identified denial trends and reimbursement issues and communicated findings to management to support process improvement initiatives.
- Ensured compliance with HIPAA regulations, payer billing guidelines, and anesthesia coding requirements including modifier and claim billing accuracy.
- Maintained productivity and quality performance standards while managing a high volume workload in a fast paced revenue cycle environment.
Insurance Reimbursement Specialist
Acclara/R1 RCM
Houston
10.2022 - 03.2025
- Coordinated retro-authorizations required for medical procedures.
- Examining eligibility and verifying benefits for treatments, hospitalizations, and procedures
- Examining patient bills for correctness and completeness, as well as gathering any missing data
- Utilizing billing software, prepare, evaluate, and send claims, including electronic and paper claim processing
- Following up on non-payment claims within the regular billing process timeline
- Inspect each insurance payment for correctness and adherence to contract discounts
- Contacting insurance providers about any payment discrepancies
- Notifying Insurance Guarantor for updated COB information via the mail or phone calls
- Updating COB information using secondary and tertiary insurance identifications
- Keeping track on Excel Spreadsheet of follow-up accounts
- Working denials for non-payment, under payment and appropriate DRG reimbursement
- Creating payment arrangements for patients and work collections accounts
- Track and organize instances of workflow disruptions.
- Handled insurance eligibility denials efficiently.
- Responded efficiently to email inquiries regarding administrative responsibilities.
- Adhered to HIPAA standards through methodical execution of tasks.
- Forwarding claims to the Coding department for review of missing or invalid ICD-10 or CPT codes
- Deferring accounts for follow-up and keeping track of timely file using Excel spreadsheets
- Performs consistent follow-up to avoid timely file and to resolve resolution
- Examine unpaid/under paid claims on behalf of St
- Taking appropriate action for 1st and 2nd level appeals process
- Contact and inform Guarantors regarding the necessary steps to resolve any outstanding insurance balance while providing payment options offered by St
- Preparing documentation and medical records to initiate the appeal process
- Formatting, preparing and sending appeals with insurance appeal forms to Insurance companies
- Responding to insurance correspondence as to take appropriate action in a timely manner
- Utilizing Insurance portals for inquires disputes and appeal updates
- Identify contractual obligations.
- Identifies problem accounts with payers: Research and corrects errors, follows-up on missing information and providing requested documentation
- Monitored financial transactions with patients.
- Answers Inbound and makes outbound telephone inquiries to/from patients and third-party payers as needed: Notates account
- Create, submit appeals within timely file
- Adhere to HIPAA polices maintains patient confidentiality
- Submitting corrected claims withing timely file deadlines
- Coordinating with Coding department for assistance with accurate CPT and Diagnosis Coding
- Ability to read and understand line items on a UB04
- Review electronic and paper denials to prepare, medical records, IB and invoices for appeals process
- Reviewed DRG ensuring proper compensation.
- Followed up with Worker Compensation on claim progress.
- Interacted with auto policy adjuster regarding claim status.
Part-time-Video Banker/Interactive Teller Machine
09.2022 - 07.2024
- Remotely processed individual teller transactions and customer service inquiries at the corporate bank location via Teller Now system
- Consistently establish new relationships and build on established customer relationships
- Maintains knowledge of bank product, services and procedures as to follow banking protocol
- Accurately completes proper steps, paperwork and procedures within the guidelines to complete and execute customer’s banking needs and request
- Proficiently explains bank charges, policies, procedures, promotions and rates in understandable terms to ensure communication to customer is effective
- Maintained compliance with various banking regulations
- Upheld customer’s confidentiality
- Communicates with management regularly to discuss new banking policies and procedures
- Served as a liaison for customers to pursue solutions on behalf of the customer to resolve issues
- Upkeep a professional appearance and behavior to maintain integrity of the bank
- Provides friendly, courteous, professional customer service for an enjoyable banking experience
- Sustains professional, respectful relationships with coworkers as to work together for the best customer service experience
Customer Service Representative-Temp
Masshealth/Automated Health System
07.2022 - 10.2022
- Interview those requesting benefits: help them complete eligibility forms and submit required verifications to obtain and validate demographic and financial information
- Evaluate submitted documents from those individuals under 65 living in the community to ensure accuracy and completeness and to support the initial and continued determination of eligibility for programs administered by MassHealth Operations
- Contact applicants to obtain information not listed on eligibility forms, contact collateral sources of information, and determine immigrant status
- Review electronic documents, updated demographic, financial, and background data for member eligibility update and make necessary corrections
- Reconcile MHO case information with information from other agencies and sources to verify continued eligibility for benefits
- Respond to member inquires and provide information regarding eligibility requirements
- Explain appeal rights, eligibility rules and procedures to customer, applicants, attorneys, advocates, providers and public officials, external agencies, the public or other parties
- Represent agency at hearing by preparing and delivering explanations of eligibility determinations
- Determining the best Health plan for members and enrolling into appropriate health plan for health care needs
- Helping to Assist and choosing with Primary Health Care Doctors based on members health plan
- Providing Health plan coverage information and informing Prior Auth approval
- Providing great Customer Service with kindness, empathy, and ethics for a wonderful customer service experience
Medical Biller Specialist
Practi-source/Coronis
03.2021 - 07.2022
- Utilize the Practi-Source online worklist system to perform follow-up activities
- Calling Insurance Payers to resolve outstanding claims and expedite payment
- Process patient payments
- Maintain strict patient confidentiality
- Document Review
- To review insurance policies to determine the coverage type, as to payment, or denials
- Preparing Claims, through e-clinicals works
- Assisting in correspondence for accurate Insurance ID numbers and demographic information
- Process new insurance policies and modify existing policies to reflect company coverage protocols or client request changes
- Constructing necessary adjustments for overpaid and underpaid claims per contractual rate
- Verbal and written communications, with management, investigators
- Critical thinking skill management
- Medical Terminology
- Coding
- Customer Service Representative
- Responsible for acting as a liaison between customers, providers, and company
- Representing the company as to the policies and procedures in the manner of resolving customers concerns and complaints, services, billing, cancelation, and general queries
- Also, address emails and voicemail queries
- Ascertain the reason why the customer is calling and professionally answer the questions 'why, what and how' To execute Data Enter on every call as a record of entry and verification
- Completes reconciliation of accounts with patient collections
- Coordinates with manager for charge additions and corrections
- Performs other duties and responsibilities as assigned
- Ability to read and understand line items on a 1500 claim form
- Working in structured work queue to obtain accounts for denial follow-up
- Formatting, structuring and sending appeals to payers
Claims Processor/CSR
Wellfleet/MedPro Group
12.2019 - 03.2021
- To manage and facilitate Verifying Claims, as an individual Claims Processor and as a team member
- Document Review
- To review insurance policies to determine the coverage type, as to payment, or denials
- Preparing Claims, through Luminex Systems, in preparation for review and compliance and completeness
- Adjustable, Administration: Process new insurance policies and modify existing policies to reflect company coverage protocols or client requested changes
- Constructing necessary adjustments for overpaid and underpaid claims per contractual rate
- Reviewing and correcting Zelis edits per scrubber
- Verbal and written communications, with management, investigators
- Critical thinking skill management
- Medical Terminology
- Coding
- CSR/ Customer Service Representative
- Responsible for acting as a liaison between customers, providers and company, representing the company as to the policies and procedures in the manner of resolving customers concerns and complaints, services, billing, cancelation and general queries
- Also, address emails and voicemail queries
- Ascertain the reason why the customer is calling and professionally answer the questions 'why, what and how.'
- To execute Data Entry on every call as a record of entry and verification
- 60 inbound calls per day
Office Manager
Fresenius Kidney Care
Bloomfield
04.2018 - 09.2020
- Overseeing Administrative Operations
- Patrol(Kronos), Maintain Patient Charts(Lexmark Systems)
- Transportation Coordinator, Account Payables, Invoice Integrity
- Patient Lab Retention and Record Keeping, Interact with Clinical Professionals i.e; Doctors, Nurses, Visiting Staff
- New Patient Administration, Patient Care Plans, Patient Removal
- Monthly Meeting, Meeting Minutes Coordinator
- Customer Service, Opening and Closing, Implement All Corporate Directives with HIPAA
- Collections on past due and out of pocket expenses
- Denials and appeals on patient account
- Claim submissions and corrected claims for reprocessing
Medical Biller Specialist/Temp Worker
Children's National Hospital
Silver Spring
06.2017 - 03.2018
- Collaborated with staff and management to optimize production and insurance billing processes using Trizetto.
- Reviewed EOBs and Medicare Remits to comprehend reimbursement details.
- Analyzed HCPCS codes for confirming medical necessity.
- Monitored rejected claims to meet submission deadlines.
- Conducted outbound calls to insurance companies regarding payments.
- Utilized Excel for effective claims tracking.
- Informed teams of updated weekly line performance data during meetings.
- Ensured accurate insurance validation for new patient entries.
- Ensured compliance with established protocols during appeal handling.
- Ensuring adherence to HIPAA compliance regulations.
- Acted as Supervisor, facilitating bank deposit logging and daily reporting.
- Resolved inquiries from billing staff regarding SOP.
- Resolved issues with denied claims for reprocessing and payment.
- Secured significant insurance reimbursements exceeding $400,000.
- Kept insurance benefit information in patient accounts updated.
- Instrumental in achieving monthly Billing Claims forecasts.
- Consistently delivered outstanding support to customers.
- Ensured accurate diagnosis and procedure codes for hospital admissions.
Medical Biller and Coder
Caring Health Center
Springfield
07.2014 - 07.2016
- Examined ICD 10 and CPT coding data to ensure correct reimbursement.
- Coordinated efforts to ensure timely payment of healthcare claims.
- Assessed and challenged denied claims.
- Responded to inquiries regarding patient billing.
- Managed outstanding accounts receivable.
- Overseeing account receivable reports for facilities.
- Recorded patient payments directly into account records.
- Processed Sliding Scale Fee applications for patients.
- Applied CPT coding knowledge to ensure accurate reimbursements.
- Compiled and submitted medical appeal documents to insurers.
Internship
Baystate Health
Holyoke
02.2015 - 07.2015
- Worked in the electronic medical record, viewing patient accounts
- Trained in 3M Encoder and abstracting software
- Assisted on applying ICD9 and ICD10 codes using coding guidelines
- Educated on the assignment of CPT procedural codes (outpatient setting)
- Introduced to DRG groupings and methodology for inpatient reimbursement
- Well established in coding quality initiatives
- Complete understanding of the coding process to support billing
- Well versed in HIPAA and patient confidentiality
- Habituated in workplace expectations, etiquette, and career pathways (written and verbal communication, teamwork, internal customer service focus)
- Knowledgeable on overall Health Information Management Operations
Personal Trainer and Influencer
Springfield
12.2011 - 05.2014
- Assist Individuals with Cardio, HIIT and interval workouts
- Help clients with weight loss and weight management
- Instruct proper form and technique with strength training workouts
- Coached clients on nutrition for healthy weight loss
- Provide personal assistance in the field of Circuit Training
Member Services Assistant/Temp
Health New England
08.2011 - 11.2011
- Processed enrollment applications for Medicare insured
- Assist and coordinate the Medicaid Disenrollment Project
- Assigned PCP's to Medicaid participants using the Care system
- Scheduled appointments for informational seminar sessions utilizing MP
- Routinely made outbound calls to confirm Medicare enrollment status
- Scanned Medical documents and filed to correct department
Administrative Assistant/Accounts Payable
C&S Wholesale Grocers
06.2007 - 08.2011
- Billed weekly bills for ad programs and new items using the C&S Voucher System
- Received and verified invoices and requisitions for goods and services
- Maintained the general ledger and updated vendor files and file number
- Prepared batches of invoices for data entry and entered invoices for payment
- Entered bill backs into the system for Grand Union Stores
- Reviewed and verify travel claims, maintained a filing system for all financial documents
- Create weekly ad planner and update daily while tracking completed planners for future review
- Retrieve GSP and Clip less report from Document Direct for GU Front Page Sell Through Recap for Completion of Front Page UPC file
- Provided reception coverage
- Assisting Grocery Manager with Front Page sale items
- Manage New Grocer Item Spread Sheet
Customer Service Representative
TeleTech
Enfield
12.2003 - 12.2005
- Handled 70-95 inbound call a day with billing inquires
- Set up payment arrangements for collection of balances
- Collected past due balances for services
- Educated on product knowledge for effective customer service
Medical Billing and Coding Rep
Wing Memorial Hospital
12.2002 - 12.2003
- Performed computerized insurance billing for Medicare
- Received reimbursements and processed claims
- Processed and collected payments from uninsured for services rendered
- Provided correct codes for outpatient, inpatient and emergency room services
Education
Bachelor of Science - Health Information Management
University of Phoenix
Tempe, AZ 01.2024 - 09.2026
Certified Medical Billing Professional/CMBP - Medical Billing/HIPAA
Medical Billing Certification
Online/RemoteAssociate's degree - Science in Health Office Information Technologies
Springfield Tech Community College
Springfield, MAHIPAA Training -
Baystate Medical Center
Skills
- Clearinghouse Denials
- Microsoft Excel proficiency
- Time management abilities
- Professionalism
- Conflict Resolution
- Multitasking Abilities
- Communication Skills
- Problem-solving abilities
- Data Analysis
- Payroll Management
- Disability claims process
- Balance reconciliation
- Claim submission
- Insurance collections
- ICD-10
- Account follow-up
- Accounts receivable management
- Insurance claims processing
- CPT code modifiers
- Reimbursements
- Claim review
- Claim Denials
- Collection calls
- Account updating
- Sales expertise
- Tracking complaints
- Prioritization
- HCPCS Codes
- Adaptive team player
- Courteous demeanor
- Account Reconcile
- Call center experience
- Follow-up skills
- Data inputting
- Financial software
- Drawer balancing
- Compliance, banking laws, and regulations
- HIPAA Guidelines
- Banking
- ICD-10
- CPT
- Workers’ Compensation Analysis
- Auto Claims Processing
- Hospice
- DRG
- Medicaid
- Medicare
- EOBs
- Remittance Advice
Education and Training
other
Certification
CMBP-Certified Medical Biller 2024
HIPAA Training, Baystate Medical Center, 06/01/15
Timeline
Accounts Receivable Analyst
National America Partners in Anesthesia
03.2025 - Current
Bachelor of Science - Health Information Management
University of Phoenix
01.2024 - 09.2026
Insurance Reimbursement Specialist
Acclara/R1 RCM
10.2022 - 03.2025
Part-time-Video Banker/Interactive Teller Machine
09.2022 - 07.2024
Customer Service Representative-Temp
Masshealth/Automated Health System
07.2022 - 10.2022
Medical Biller Specialist
Practi-source/Coronis
03.2021 - 07.2022
Claims Processor/CSR
Wellfleet/MedPro Group
12.2019 - 03.2021
Office Manager
Fresenius Kidney Care
04.2018 - 09.2020
Medical Biller Specialist/Temp Worker
Children's National Hospital
06.2017 - 03.2018
Internship
Baystate Health
02.2015 - 07.2015
Medical Biller and Coder
Caring Health Center
07.2014 - 07.2016
Personal Trainer and Influencer
12.2011 - 05.2014
Member Services Assistant/Temp
Health New England
08.2011 - 11.2011
Administrative Assistant/Accounts Payable
C&S Wholesale Grocers
06.2007 - 08.2011
Customer Service Representative
TeleTech
12.2003 - 12.2005
Medical Billing and Coding Rep
Wing Memorial Hospital
12.2002 - 12.2003
Certified Medical Billing Professional/CMBP - Medical Billing/HIPAA
Medical Billing Certification
Associate's degree - Science in Health Office Information Technologies
Springfield Tech Community College
HIPAA Training -
Baystate Medical Center