ROSLYN R. HOLMES

• Account Resolution Revenue Cycle Operations.
• Direct, lead, and manage revenue cycle operations for Commercial payer’s accounts receivable to zero balance resolution.
• Oversee Revenue Cycle Commercial Managed Care Payer account receivables, with a net worth of $450+ million for 9 Wellstar facilities
• Plan, coordinate, and control all Commercial Revenue Cycle departments (Billing, Insurance Follow-Up, Denials & Appeals, and Payment Variance department activities including, but not limited to supervising, training, interviewing, hiring, counseling, and terminating employees, as circumstances dictate.
• Implement and optimize departmental best practices, policies, and standardized workflows for revenue cycle operations through continuous improvement initiatives.
• Encourage and maintain productive inter-departmental relationships through collaborative communication, leadership, and end to end problem solving.
• Lead, manage, and supervise professional level staff, providing direction and guidance, creating a team environment through training, recognition/evaluation, and in-service education which produces optimum work habits and job performance.
• Direct and Indirect Revenue Cycle Management, to maintain a working knowledge of all-departmental follow-up processes and functions, responding appropriately to inquiries on patient and insurance accounts, to include, addressing concerns related to contract reimbursement discrepancies.
• Oversee the assessment of claim denials and remittance payments to identify potential discrepancies and trends in performance, for all contracted Managed Care payers, per our contractual agreement/methodology.
• Ensure team members follow-up on technical denial and underpayment claims promptly and is held accountable for aged receivables.
• Led the Denials & Appeals and Payment Variance Manager in analyzing technical denials, payment discrepancy reporting, to identify trends and issues impacting the overall accounts receivable.
• Mitigation planning developed of aging outstanding inventory to resolution.
• Posting and approval of uncollectible revenue through an adjustment workflow process.
• Coordinate and oversee assigned vendor relationships, including attending monthly or quarterly meeting.

Career Highlights:

• Conduct daily/weekly/monthly operational, internal calls and payer calls/ JOC’s, to improve workflows for efficiency, holding the payer to our standards and clear expectations for a communicative partnership in pursuit for timely cash collections/ account resolution.
• Function as the provider payer relations/payer liaison, responsible for interacting with payers to rectify barriers related to erroneous payer denials, underpayment recovery, and resolution of non-payment, to paid accounts.
• Oversee the development and efficiency of insurance follow-up, denials & appeals, and underpayment recovery through a payer reconsideration/ appeal workflow.
• Policies & procedures utilized to ensure workflows are identifiable and comprehensible/ streamlined across Revenue Cycle teams.
• Creation of a Payer Escalation Process, partnering with 5 major healthcare payers, 3 Health Exchange, to include 3 CMO’s and Medicare Advantage, in efforts to recover and resolve outstanding account receivables.
• Lead initiatives to timely resolution of claim edits, submission of claims within the payer specified timeframes, and managing the unbilled inventory in efforts to reduce days to bill.
• Establish workflows to meet KPI’s: focus on AR days > 90, cash collections, denial management, and underpayment recovery.
• Trained new employees on proper protocols and customer service standards.
• Interacted well with customers to build connections and nurture relationships.
• Trained and guided team members to maintain high productivity and performance metrics.
• Reported issues to higher management with great detail.
• Observed each employee's individual strengths and initiated mentoring program to improve areas of weakness.
• Monitored daily cash discrepancies, inventory shrinkage and drive-off.

• Network Relations.
• Manage the day-to-day operations of the provider network department.
• Develop, implement, and monitor quality operational initiatives to achieve healthy outcomes for assigned projects.
• Provide guidance in the resolution of complex claim payment and provider system set-up issues.
• Receive and respond to urgent provider issues escalated.
• Ensure standards are established, met and maintained.
• Plan, coordinate, and participate in scheduled and unscheduled meetings with provider network specialist staff, to conduct orientations, train on health plan policies and procedures, deliver materials, inquiring on contracting with the company’s multiple product lines.
• Manage the Network Provider Relations team and PR Coordinators, to ensure goals and objectives are met through effective hiring, performance management, training, coaching, and career development.

Career Highlights:

• Contribute to overseeing the planning of health plan-sponsored events, act as host of such events
• Develop and recommend updates to policies and procedures and ensure provider manuals are accurate and up to date.
• Manage the day-to-day workflow of the network operation account functions in compliance with health plan, corporate, and state policies, procedures, and guidelines.
• Participate in provider contracting activities to minimize contract implementation issues/errors, provider abrasions.
• Maintained positive customer relations by addressing problems head-on and implementing successful corrective actions.
• Evaluated employee performance and conveyed constructive feedback to improve skills.
• Established team priorities, maintained schedules and monitored performance.
• Maximized performance by monitoring daily activities and mentoring team members.
• Resolved staff member conflicts, actively listening to concerns and finding appropriate middle ground.
• Accomplished multiple tasks within established timeframes.
• Managed and motivated employees to be productive and engaged in work.

• Management (Underpayments & Overpayments).
• Conduct pricing and modeling contract audits for Commercial, Worker comp, Government, Managed Care payers, with a net worth of $450+ million for 5 Wellstar Hospitals.
• Onboarded and trained new staff to keep team efficient and prepare team members to effectively handle demands of simultaneous and large-scale contracts.
• Worked closely with account team to identify areas to improve cash flow and leverage tools to improve cash flow from contracts.
• Hired, managed, developed and trained staff, established and monitored goals, conducted performance reviews and administered salaries for staff.
• Built and managed processes for tracking and monitoring department performance.
• Identified opportunities to streamline processes and improve office operations and efficiency.
• Responsible for ensuring staff resolve payment discrepancies, late payments, and denied payments with individual payers (Managed Care, Commercial, Government, Managed MCR, and Managed MCD), ensuring proper claim and payment resolution..
• Preparation of payer JOC meetings between the hospital and Managed Care organization to discuss/resolve contractual and operational issues to enhance contract performance.
• Work with managed care teams to interpret and enforce payer contract terms.
• Exemplify, encourage, and support collaborative, inclusive team efforts that produce effective internal and external working relationships and trust.
• Manage staff to ensure proper department policies and processes are effectively implemented, guided towards a favorable outcome to satisfy the client.
• Engage and provide input in major enterprise negotiations with payers.

Career Highlights:

• Manage to reconcile vendor invoices steadily decreasing, by $150K and oversee front and back-end denial auditors, for Patient Access and other departmental educational trainings.
• Proactively build and strengthen relationships that nurture provider, inter-departments, and payer partnerships.
• Function as the provider payer relations/payer liaison, responsible for interacting with payers to rectify barriers related to erroneous payer denials, underpayment recovery, and resolution of non-payment, to paid accounts.

• Government Logging Commercial/Medicare /Medicaid Discrepancy, Provides introductory ongoing training, support, and education to staff team members, to ensure policies and procedures are followed and adhered to.
• Responsible for weekly/ month end financial reconciliation reports of outstanding accounts receivables expected payer reimbursement, for 23 facilities.
• Manages cost- effective leading payer contracts for hospital reimbursements.
• Build relationships between departmental areas to accurately analyze and resolve contractual reimbursement disputes.

Career Highlights:

• Development and implementation of projects and department actions plans for logging area.
• Oversee government/managed care reimbursement analysts, ensuring timely and accurate account escalation of adjustments and negotiated reimbursements recovery for underpayment discrepancies.
• Achieved results by working with staff to meet established targets.
• Helped meet changing demands by recommending improvements to business systems or procedures.
• Evaluated staff performance and provided coaching to address inefficiencies.

• Facilitator over the reimbursement “Core Department Staff Training” to ensure continuous high level contract performance impact.
• Streamlined operational efficiencies and communication with multiple departments and payer relationships.
• Responsible for non-par payer reimbursement negotiations, of which contributed to over 7 to 10% of reimbursement.
• Identity payer trends, assist with resolving billing and or payer contractual issues, denials, and appeals.

Career Highlights:

• Key member on the Blue Cross Blue Shield Special Projects SWAT Team, effectively researching/resolving contractual payer reimbursement disputes.
• Lead team member for Managed Care payers (Cigna, Blue Cross Blue Shield, UHC, Aetna, Humana, etc.) recovery of high dollar trauma accounts greater than $100K.
• Skilled at working independently and collaboratively in a team environment.
• Self-motivated, with a strong sense of personal responsibility.
• Worked well in a team setting, providing support and guidance.
• Proven ability to learn quickly and adapt to new situations.
• Worked effectively in fast-paced environments.
• Managed time efficiently in order to complete all tasks within deadlines.
• Used critical thinking to break down problems, evaluate solutions and make decisions.
• Identified issues, analyzed information and provided solutions to problems.
• Participated in team projects, demonstrating an ability to work collaboratively and effectively.

• Manage monthly AR reports on outstanding Government (Medicare/Medicaid) and Managed Care payers (Aetna, Blue Cross Blue Shield, Cigna, Aetna, Humana, and UHC)
• Assist with resolving physician billing, non-payment of accounts receivable
• Physician payment posting of monthly AR to outstanding insurance and patient accounts
• Front/Back-office coordinator for patient registration, insurance verification, and customer relations
• Coordinate patient counseling of insurance benefits and patient payment plan agreements.
• Maximized cash flow through optimal billing and collection processes.

• Initiate hospital hardcopy billing for several contracted Managed Care payers.
• Insurance follow-up and collections, responsible for reviewing unpaid, underpaid, denied hospital claims for resolution.
• Works independently to secure reimbursement, identifying, and communicating payment issues and/or trends.

Career Highlights:

• Manage insurance follow-up through payer disputes, escalation level reviews, for an overall provider satisfaction of AR days at 47, contributor to meeting facility monthly cash goals.
• Led Cigna operational call, identified trend of outpatient radiology services processing in error - underpayment recovery with a financial impact over $20K.