Tisha Carmel
Louisville,KY
Overview
20
20
years of professional experience
Work History
Claims Examiner / Auditor
UMass Chan Medical School, Health and Criminal Justice Dept
01.2021 - Current
- Conducts quality assurance audits for all lines of business to ensure accuracy and consistency
- Identifies prevalent trends for accurate claims processing and adjudication, which includes developing and presenting potential solutions to management
- Works to create complex analyses and reports using Microsoft Excel, Microsoft Access, and other systems as necessary
- Assists in development of action plans to address quality deficiencies
- Handles all prison invoicing
- Works closely with finance, contracting, and operations to ensure lines of communication are kept open with processing and auditing related issues
- Tracks and monitors claims to identify missing charges, duplicate payments, coding errors, rejected EDI's, and accuracy of 835 and 837 processing
- Works to resolve difficult or complex claims and recommends related training and staff development opportunities to improve invoice processes
- Works with providers to correct any billing issues to improve the billing and invoicing processes.
Hospital Analyst / Auditor
Bottom Line Systems
01.2019 - 01.2021
- Identified underpayments by reviewing contracts, state guidelines, reimbursement methodologies and other methods
- Reviewed explanation of benefits and incoming correspondence from patients and payors
- Made outgoing calls to payors and patients to determine benefits to determine proper payment
- Posted payments, work end of month reports and adjustments
- Prepared and submitted letters to payor or patient via email, USPS, and fax.
Auditor / Payment Integrity Specialist
Cotiviti (formerly Connolly)
01.2013 - 01.2019
- Managed the claims auditing process to include locating trends and surpassing standards of productivity and quality
- Reached and analyzed documents to identify overpayments and correct missing information
- Ensured compliance with Medicaid/Medicare guidelines Created training materials for other employees
- Awarded the Cotiviti Professional and Reliable Award for excellent work performance
- Developed a concept that generated over $300k a month for Medicaid audits
- Located over $5 Million in overpayments each year for the past five years.
Claims Auditor
HMS
01.2012 - 01.2013
- Identified medical claim overpayments for the Managed Medicaid line of business
- Analyzed filter results that targeted potential overpayments through policy provisions and researched State Laws for limitations and exclusions
- Navigated multiple client systems to validate overpayments
- Remained knowledgeable of duplicates, eligibility, surgical procedures, provider contract, fee schedules, and application of CCI edits
- Achieved and maintained 99% quality on audits.
Senior Claims Examiner
Firstsource
01.2004 - 01.2012
- Adjudicated health claims for Molina Healthcare and performed recovery work for Texas Medicaid
- Trained on multiple contracts with unique procedures and benefits
- Made daily re-pricing and adjustments
- Ensured high financial and statistical quality
- Recovered COB overpayments and duplicate claims
- Trained at a moment's notice on new contracts quickly and efficiently.
Education
Exercise Science
IUPUI
Indianapolis Skills
- Epic
- ICD-9
- ICD-10
- CPT
- PPO
- HMO
- Indemnity
- Medicaid / Medicare
- Rims
- Steps
- Facets
- Citrix
- MS Office
- HIPAA
- Medical Terminology
Career Experience
- Claims Examiner / Auditor, UMass Chan Medical School, Health and Criminal Justice Dept, 2021-01-01, Present, Conducts quality assurance audits for all lines of business to ensure accuracy and consistency., Identifies prevalent trends for accurate claims processing and adjudication, which includes developing and presenting potential solutions to management., Works to create complex analyses and reports using Microsoft Excel, Microsoft Access, and other systems as necessary., Assists in development of action plans to address quality deficiencies., Handles all prison invoicing., Works closely with finance, contracting, and operations to ensure lines of communication are kept open with processing and auditing related issues., Tracks and monitors claims to identify missing charges, duplicate payments, coding errors, rejected EDI's, and accuracy of 835 and 837 processing., Works to resolve difficult or complex claims and recommends related training and staff development opportunities to improve invoice processes., Works with providers to correct any billing issues to improve the billing and invoicing processes.
- Hospital Analyst / Auditor, Bottom Line Systems, 2019-01-01, 2021-01-01, Identified underpayments by reviewing contracts, state guidelines, reimbursement methodologies and other methods., Reviewed explanation of benefits and incoming correspondence from patients and payors., Made outgoing calls to payors and patients to determine benefits to determine proper payment., Posted payments, work end of month reports and adjustments., Prepared and submitted letters to payor or patient via email, USPS, and fax.
- Auditor / Payment Integrity Specialist, Cotiviti (formerly Connolly), 2013-01-01, 2019-01-01, Managed the claims auditing process to include locating trends and surpassing standards of productivity and quality., Reached and analyzed documents to identify overpayments and correct missing information., Ensured compliance with Medicaid/Medicare guidelines., Created training materials for other employees., Awarded the Cotiviti Professional and Reliable Award for excellent work performance., Developed a concept that generated over $300k a month for Medicaid audits., Located over $5 Million in overpayments each year for the past five years.
- Claims Auditor, HMS, 2012-01-01, 2013-01-01, Identified medical claim overpayments for the Managed Medicaid line of business., Analyzed filter results that targeted potential overpayments through policy provisions and researched State Laws for limitations and exclusions., Navigated multiple client systems to validate overpayments., Remained knowledgeable of duplicates, eligibility, surgical procedures, provider contract, fee schedules, and application of CCI edits., Achieved and maintained 99% quality on audits.
- Senior Claims Examiner, Firstsource, 2004-01-01, 2012-01-01, Adjudicated health claims for Molina Healthcare and performed recovery work for Texas Medicaid., Trained on multiple contracts with unique procedures and benefits., Made daily re-pricing and adjustments., Ensured high financial and statistical quality., Recovered COB overpayments and duplicate claims., Trained at a moment's notice on new contracts quickly and efficiently.
Timeline
Claims Examiner / Auditor
UMass Chan Medical School, Health and Criminal Justice Dept
01.2021 - Current
Hospital Analyst / Auditor
Bottom Line Systems
01.2019 - 01.2021
Auditor / Payment Integrity Specialist
Cotiviti (formerly Connolly)
01.2013 - 01.2019
Claims Auditor
HMS
01.2012 - 01.2013
Senior Claims Examiner
Firstsource
01.2004 - 01.2012
Exercise Science
IUPUI
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