Krishawna Hines
Macon
Summary
Results-driven Senior AR Billing and Coding/Appeal & Denial Specialist with over 20 years of experience in billing, coding, and complex claim analysis. Expertise in denials and grievance resolution, insurance verification, and regulatory compliance. Proven track record in managing high-value medical accounts and efficiently resolving AR denials. Proficient in diverse medical software applications, committed to enhancing revenue cycle processes through innovative problem-solving and quality assurance strategies. Focused on optimizing operational efficiency while ensuring adherence to industry standards and best practices.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Senior Billing and Coding/ Denial and Appeal Specialist
HBCS
New Castle, DE
07.2018 - 11.2023
- Optimized electronic billing and coding processes for hospital DME, laboratory, oncology, and professional claims.
- Expertly navigated and utilized diverse medical software applications, including Waystar, nThrive, Copilot, Epic, Cerner, STARS, AMA, Allscripts, Meditech, EDI, ProPM, FACS, FinThrive, and Tiger.
- Facilitated collaborative efforts to identify and address denial issues, enhancing overall revenue recovery.
- Conducted comprehensive reviews of appeals and grievances to ensure compliance with organizational standards.
- Managed posting of insurance payments and adjustments to ensure compliance with payer agreements.
- Facilitated resolution of complex claims through detailed investigation and assessment of relevant data.
- Facilitated accurate reconciliation and timely submission of claim rejects and edits to ensure compliance.
- Specialized in processing and managing claims for Medicaid, Medicare, commercial liability, and workers' compensation, optimizing reimbursement workflows.
- Achieved accurate insurance verification and eligibility confirmation through effective communication with carriers and utilization of online portals.
- Conducted thorough analysis of patient demographics to enhance service delivery and patient care.
- Reviewed and processed incoming correspondence from insurance carriers, maintaining compliance with industry standards.
- Conducted thorough analysis and resolution of patient and payer inquiries.
- Oversaw management of denials, late payments, and misapplied or missing claim payments.
- Surpassed quality assurance benchmarks and enhanced productivity metrics.
- Administered processing of insurance and payer refunds and overpayments.
- Mastered navigation of various medical software applications to enhance operational efficiency.
- Investigated and mitigated persistent denial trends to support revenue recovery efforts.
- Implemented corrective measures to minimize payment delays and reduce account age.
- Coordinated multi-channel communication efforts to ensure clarity and responsiveness for payers and patients.
- Facilitated resolution of inquiries and streamlined claim processing operations.
- Responded proactively to organizational demands, ensuring timely completion of critical projects while upholding quality assurance and productivity standards.
- Oversaw management of high-value hospital accounts exceeding $999,999. Led comprehensive follow-up on AR denials to enhance financial performance.
- Documented case progress and outcomes in compliance management systems.
- Trained new staff on appeal processes and operational protocols to ensure consistency.
- Developed comprehensive reports on appeal outcomes to support strategic decision-making initiatives.
AR Denials and Appeals Specialist
RC Billing
Cedar Park, TX
12.2023 - Current
- Evaluated and validated the accuracy of radiation oncology appeals to ensure adherence to regulatory standards.
- Developed comprehensive replies to appeal inquiries to maintain clarity and thoroughness.
- Coordinated efforts with cross-functional teams to enhance efficiency in resolving intricate billing disputes.
- Oversaw meticulous record-keeping of appeal cases, ensuring accurate tracking of progress and outcomes.
- Conducted detailed reviews of rejected claims, rectifying errors to facilitate successful claim resubmission and enhance operational efficiency.
- Analyzed, monitored, and reported denial trends affecting claim adjudication processes.
- Developed appeal letters to ensure compliance with current clinical standards and facility guidelines, utilizing comprehensive medical records.
- Monitored appeal statuses and provided timely follow-up support. Assisted in tracking progress and ensuring all necessary documentation was submitted. Collaborated with team members to address any outstanding issues.
- Utilized phone and carrier websites to streamline processes for resolving claim denials.
- Analyzed and prioritized aging accounts receivable over 120 days, focusing on high-value balances in descending order.
- Maintained up-to-date knowledge of relevant laws and CMS regulations to uphold carrier accountability and operational integrity.
- Analyzed and organized documentation requests from insurance carriers, providing accurate and prompt responses.
- Coordinated efforts with insurance representatives to ensure timely collection of unpaid balances.
- Reviewed medical diagnosis codes and identified bundled CPT errors to support accurate claims processing. Assisted in managing authorization modifiers and overlapping plan identification numbers to improve operational efficiency. Submitted claims on time while meeting eligibility requirements.
- Analyzed hold reports to facilitate efficient claim resolution.
- Analyzed carrier adjustments and executed postings to ensure accurate and timely updates in the system.
- Processed refunds and assisted with carrier overpayments resolution. Supported team in managing financial discrepancies and ensuring accurate transactions. Facilitated communication between departments to streamline refund processes.
- Collaborated with clinical and health information management departments to rectify billing discrepancies.
- Trained new staff on appeal processes and best practices for documentation.
- Identified trends in appeal data, recommending improvements to reduce recurrence of issues.
- Led initiatives to streamline appeal workflows, enhancing overall operational efficiency.
- Managed high-stress situations with professionalism, ensuring that appeals were handled promptly and accurately even under tight deadlines or heavy caseloads.
- Consistently met or exceeded performance metrics, demonstrating a strong understanding of the claims review process and an unwavering commitment to achieving positive results for clients.
Community Health Worker
Quality Insights
09.2017 - 07.2018
- Facilitated educational initiatives and resource distribution for patient populations identified by medical eligibility criteria in collaboration with State of Delaware.
- Facilitated client phone calls and distributed preventative reading materials to educate patients on benefits of cancer and diabetic screenings.
- Spearheaded patient education initiatives on community resources and programs for effective diabetes management.
- Ensured adherence to timelines, driving project milestones to successful completion.
- Facilitated client navigation through complex health care systems.
- Managed logistics for client appointments and class schedules to ensure efficient operations.
- Provided comprehensive guidance on healthy lifestyle choices and disease management to support diabetic patients' well-being.
- Developed and executed comprehensive health programs focused on educating diabetic patients, resulting in decreased cancer diagnoses across Delaware and surrounding regions.
- Streamlined patient navigation within healthcare systems to improve overall experience and support care continuity.
- Evaluated patient data to develop customized preventive materials.
- Managed project timelines and met critical milestones to support state-contracted health program objectives.
- Collaborated with community programs to strengthen diabetes management resources.
- Designed and implemented outreach strategy utilizing phone consultations and targeted mailings to promote patient participation in preventive screenings.
Senior Billing and Coding Specialist/ Financial Counselor
Bayhealth Medical Center
03.2013 - 09.2017
- Oversaw preparation of patient financial documents for review by medical director and CFO.
- Facilitated communication with patients to address concerns about medical claims and financial assistance processes.
- Conducted initial patient screenings to determine eligibility for financial assistance.
- Designed and implemented suitable payment plans to facilitate debt recovery.
- Reviewed and revised rejected claims to facilitate accurate resubmission for professional and hospital services.
- Analyzed and reported on payer denial trends to identify areas for improvement.
- Composed appeal and grievance letters for formal submission.
- Evaluated and addressed incoming payer correspondence to enhance operational efficiency in issue resolution.
- Analyzed payment plan statuses to proactively address potential defaults and safeguard revenue streams.
- Facilitated timely reporting and transfer of delinquent accounts to collections to optimize recovery efforts.
- Developed systematic approaches for processing employee payroll deductions, improving overall payroll operations.
- Facilitated initiation of Delaware Medicaid eligibility qualification processes.
- Analyzed patient demographic records and verified insurance eligibility to maintain compliance and enhance service quality.
- Executed insurance eligibility verification through direct phone communication and payer portals.
- Guided patients in understanding financial obligations and billing practices.
- Administered processing of patient copayments, deductibles, coinsurance, and other out-of-pocket expenses to ensure accurate patient account management.
- Coordinated outreach to connect patients and families with appropriate community resources and programs based on specific requirements.
- Conducted comprehensive reviews of client financial situations to ensure alignment with established short- and long-term objectives.
- Provided expert guidance on financial plans and strategies to enhance client understanding.
- Facilitated client interviews to assess income, expenses, financial objectives, and risk tolerance.
- Facilitated patient navigation through complex financial processes, including Medicaid enrollment and payment plans.
- Enhanced revenue cycle efficiency to minimize payer denials and improve cash flow.
- Established robust payment tracking systems to enhance financial accuracy.
- Oversaw strategic management of delinquent accounts to enhance cash flow.
- Facilitated interdepartmental collaboration by liaising between patients, medical directors, and CFO to align financial strategies with patient care objectives.
- Implemented systematic verification processes for patient demographics and insurance details, ensuring precise billing and reducing claim discrepancies.
- Collaborated with healthcare providers to ensure proper documentation for optimal coding practices.
- Reviewed and validated medical records, ensuring all codes adhered to industry standards and guidelines.
- Managed high volumes of medical records efficiently while maintaining strict attention to detail during the coding process.
Senior Billing and Coding Representative/ Patient Technician
Delaware Cardiovascular Associates
02.2008 - 03.2013
- Facilitated accurate submission of billing and coding claims to ensure timely reimbursement.
- Assisted in reviewing denial and grievance submissions. Supported the appeal process by gathering necessary documentation. Collaborated with teams to ensure timely responses to grievances.
- Facilitated patient registration processes to streamline intake procedures. Assisted patients in completing necessary documentation for efficient service delivery. Supported administrative staff in maintaining accurate patient records.
- Assisted in verifying insurance details and updating records. Supported clients by providing accurate information regarding their insurance status. Facilitated communication between clients and insurance providers to resolve discrepancies.
- Facilitated patient preparation for EKG Holter and loop monitoring to ensure accurate data collection.
- Oversaw medication management revisions and documentation practices to enhance patient care. Led initiatives to streamline medication tracking and reporting processes. Championed best practices in medication documentation across departments.
- Facilitated comprehensive preparation of patient charts to support efficient healthcare delivery.
- Assisted in scheduling follow-up appointments for stress tests and echocardiograms. Coordinated vascular and cardiac catheterization appointments to support patient care. Facilitated communication between departments to streamline scheduling processes.
- Facilitated prior authorization approval processes for cardiovascular testing and medication management.
- Facilitated faxing and filing processes to maintain organized electronic medical records. Organized documentation to support efficient retrieval and management of patient information. Assisted in maintaining compliance with record-keeping standards.
- Documented and responded to patient and provider communications via phone, email, and fax to ensure timely information exchange.
- Conducted thorough review and preparation of medical transcriptions to ensure accuracy before EMR integration.
- Conducted thorough reviews of implemented preliminary physical tests to maintain testing integrity.
- Assisted in verifying prescriptions and processing refill requests. Supported pharmacy operations by ensuring accurate medication dispensing. Collaborated with healthcare professionals to address patient inquiries regarding prescriptions.
- Ensured protection of patient information and records through stringent security measures.
- Facilitated transition of patient physical charts into EMR system to enhance data accessibility.
- Executed sanitation protocols for medical office and equipment to ensure a sterile environment.
- Optimized patient flow by coordinating check-in and check-out appointments.
- Coordinated interactions among patients, healthcare providers, and insurance representatives to streamline processes.
- Conducted thorough claims coding reviews to ensure accurate claim submissions.
- Responded to provider pharmacy and carrier inquiries, providing accurate information and assistance to enhance service delivery.
- Facilitated resolution of benefit disputes to ensure compliance with organizational policies.
- Ensured compliance with policies while addressing client requirements.
- Conducted thorough documentation reviews to ensure accuracy and eliminate errors.
- Guided clients in understanding benefits while ensuring effective communication with healthcare partners for seamless claims management.
- Maintained comprehensive understanding of evolving policies to facilitate accurate implementation and guidance.
Education
Criminal Justice, Public Health
Wilmington University
05.2003
Skills
- Claim analysis and resolution
- Denial reconciliation
- Healthcare coding proficiency
- Proficient in medical terminology
- CPT coding expertise
- Analytical skills
- Software technical skills
- HIPAA compliance expertise
- Radiation oncology billing
- Microsoft Teams proficiency
- Insurance program management
- Remote work proficiency
Certification
- Georgia/ Delaware 2023-2025
- Life Insurance
- Final Expense
Timeline
AR Denials and Appeals Specialist
RC Billing
12.2023 - Current
Senior Billing and Coding/ Denial and Appeal Specialist
HBCS
07.2018 - 11.2023
Community Health Worker
Quality Insights
09.2017 - 07.2018
Senior Billing and Coding Specialist/ Financial Counselor
Bayhealth Medical Center
03.2013 - 09.2017
Senior Billing and Coding Representative/ Patient Technician
Delaware Cardiovascular Associates
02.2008 - 03.2013
Criminal Justice, Public Health
Wilmington University