CARALI RODRIGUEZ VIZCARRONDO
Healthcare Industry
Gurabo,PR
Summary
Hardworking and motivated professional with several years of experience and record of success in industry. Solid history balancing team performance, customer service targets and business objectives. Dedicated to working closely with employees to maximize productivity and optimize procedures. Decisive leader with good planning and organizational skills.
Overview
23
23
years of professional experience
6
6
years of post-secondary education
1
1
Certification
Work History
Manager I-Financial Recovery Ops
MSO OF PUERTO RICO-MMM HEALTHCARE
1 2021 - Current
- Ensure all coding associated with medical policy is implemented correctly and in a timely manner
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
- Assist in validating claim compliance reports and compliance internal audits
- Demonstrates a high level of integrity and innovative thinking and actively contributes to the success of the team
- Assists in ensuring that Notification/PDR/Appeal letter templates and language are appropriate and in accordance with CMS regulations.
- Assist with monitoring corrective action plans and takes appropriate interventions to return to state of compliance when necessary
- Assist with training, orientation and mentoring of new and existing financial recovery ops specialist employees
- Responsible for yearly CMS Final Rule interpretation, divulgation, and staff training
- Establish and promote teamwork within the department, participating fully and with commitment
- Supervise audit unit’s staff (12 Auditors, 1 Supervisor, 1 Clerk) following company policies and any applicable laws
- Responsible for day-to-day oversight of claims auditing in order to assure prompt accurate payment of claims within the established policies and procedures
- Responsible to analyze system editing (QNXT, PMHS) in order to assure the accuracy in the policies implementations
- Create reports, if necessary
- Responsible to coordinate activities related to regular financial recovery identified in the internal audits or referred by other vendors to assure the prompt recovery of overpayments
- Responsible for creating weekly and monthly reports of audit findings and participate in the development of corrective action plans in coordination with Quality Assurance
- Refer situations that require departmental communication
- Monitor individual performance and ensure it meets expected quality and performance objectives
- Prepare weekly and monthly reports to the CFO, Director or Claims AVP about internal audits, financial recovery, etc
- Coordinates with other departments to apply the actions required to deal with claims issues
- Submit recommendations to the Claims Operation Manager or the Claims AVP about new procedure to improve effectiveness in the audits area
- Represents the Director during absence, vacation and when needed
- Manage Financial Recovery auditor’s payroll on workday platform and administrative work related
- Manage external vendors performance; implement strategies and plans to address areas of improvement; identify and address needs on an ongoing basis; provide frequent performance feedback
- Employ proper claim handling techniques to optimize recoveries
- Develop and execute a strategic file management plan that achieves optimal file resolution and business results
- Implement strategies to maximize recoveries and ensure they’re appropriately and timely allocated to files
- Successfully leverage data, management information and technology to identify and make the most of opportunities to support business strategies and improve results
- Maintain current knowledge of field, regulations, procedures, and case decisions affecting appropriate jurisdictions
- BCP Coordinator Leader
- Ensured compliance with local, state, federal tax regulations; timely filing of all required documents, mitigating potential penalties or fines
- Completes other projects and duties as assigned
- Checked payroll, vendor payments, and other accounting disbursements for accuracy and compliance
- Achieved departmental goals by developing and executing strategic plans and performance metrics.
- Enhanced provider satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service.
Financial Recovery Supervisor
MSO OF PUERTO RICO-MMM HEALTHCARE
01.2018 - 01.2021
- Supervise audit unit’s staff (Auditor I, Financial Recovery Auditor, Audit Clerk and Check Run Specialist) following company policies and any applicable laws
- Responsible for day-to-day oversight of claims auditing to assure prompt accurate payment of claims within the established policies and procedures
- Responsible to analyze system editing (QNXT, PMHS) to assure the accuracy in the policies implementations
- Create reports, if necessary
- Responsible to coordinate activities related to regular financial recovery identified in the internal audits or referred by other vendors to assure the prompt recovery of overpayments
- Responsible for creating weekly and monthly reports of audit findings and participate in the development of corrective action plans in coordination with Quality Assurance
- Participate, in coordination with Quality Assurance, in new and existing staff training
- Refer situations that require departmental communication
- Audit unit’s personnel in order to maintain company standards and departmental goals and objectives
- Prepare weekly and monthly reports to the Claims Operation Manager or Claims AVP about internal audits, financial recovery, etc
- Coordinates with other departments in order to apply the actions required to deal with claims issues
- Submit recommendations to the Claims Operation Manager or the Claims AVP about new procedure to improve effectiveness in the audits area
- Responsible for the monthly staff evaluation and the implementation and monitoring of the corrective action plans as necessary in an objective and impartial process
- Overview and monitor weekly check run process for both companies in PMHS and QNXT
- Represents the Manager during absence, vacation and when needed
- Special projects could be assigned
- Manage Financial Recovery auditor’s payroll and administrative work related.
Collection Department Supervisor
De Jesús & Matos Medical Imaging
01.2014 - 01.2018
- Track and report individual performance and attendance results
- Promote the importance of being a team player
- Complete special projects on a timely basis
- Represent department interest at internal and external functions/meetings
- Accountable for accepting personal responsibility for the quality and timeliness of work assigned and assumes ownership of the results; maintain high work ethics; takes initiative to actively improve performance
- Fiscally responsible to the company
- Confident in the ability to make spontaneous decisions when required and deductive/methodical decisions where appropriate
- Provide training and retraining for the staff
- Manage and oversees management of the day-to-day operations of the Accounts Receivable Department ensuring adherence to policies and procedures
- Establishing priorities and managing workload
- Develop, maintain and monitor all billing procedures
- Follow up on all receivable balances
- Monitor write-offs with the objective of minimizing these losses
- Prepare monthly billing reports to Administrative Director
- Supervise all billing staff to ensure accuracy, efficiency, and timeliness of claims
- Actively pursue all non-payments identifying the cause and providing a corrective solution
- Oversees the accurate posting of payments received from all health plans
- Monitoring and follow-up of claims not paid in a timely manner
- Oversees the hiring and supervision of personnel, which includes work allocation, training, and problem resolution; evaluates performance and makes recommendations for personnel actions, including termination; motivates employees to achieve peak productivity and performance
- Develop and implement policies and procedures to ensure efficient and safe operation of the department and to meet established goals and timelines
- Works as liaison with the billing department, to facilitate problem solving and data collection appropriate to patient and insurance billing.
Administrative
Family Business
01.2010 - 01.2014
- Establishing priorities and managing workload
- Answering telephone calls professionally
- Filing paperwork and photocopy
- Dealing with queries quickly and professionally
- Resolving administrative queries
- Maintaining equipment by completing preventive maintenance, arranging for repairs and monitoring equipment operation
- Payroll
- Product providers’ payments.
Claim Analyst II
Medical Card System, Inc.
01.2009 - 01.2010
- Adjudication of physician, laboratory, radiology, emergency room claims, hospital and institutional/professional specialty claims
- Knowledge on prospective payment systems like DRG and outpatient prospective payment system (APC)
- Knowledge in medical coding (ex
- CPT, HCPCS, ICD9-CM, HIPPS) and related standards
- Knowledge in Medicare reimbursement methodology (ex
- APC, ASC, RBRVS, etc.) and related standards
- Determine acceptability of evidence submitted and necessity for additional review
- Resolve claim issues
- Maintain departmental standards for quality and production goals
- Ability to interpret and apply written guidelines applicable to claim adjudication
- Maintain compliance with claim routing procedures
- Maintain compliance with inventory control procedures
- Communicate system and/or specific claim issues in a timely manner to Department Supervisor
- Analyze the correct way for avoiding the excess payment
- Process nonparticipant provider claims in a timely manner as CMS rule and company policies and procedures
- Evaluate and process claims issues sent from Appeals and Grievance Department
- Identify discrepancies and outstanding issues and secure additional information while investigating within the time frames establish by policy and procedures
- Communicate with Health Services Department for pre-certifications process and with Finance Department for claims payment
- Process reimbursement of patients
- Perform other duties as required by supervisor.
Claim Analyst
Salud Dorada con Medicare
01.2008 - 01.2009
- Adjudication of physician, laboratory, radiology, emergency room claims, hospital and institutional/professional specialty claims
- Perform claims re pricing according to written procedures for specific vendor
- Determine member eligibility
- Knowledge on prospective payment systems like DRG and outpatient prospective payment system (APC)
- Knowledge in medical coding (ex
- CPT, HCPCS, ICD9-CM, HIPPS) and related standards
- Knowledge on medical terminology
- Knowledge in Medicare reimbursement methodology (ex
- APC, DRG, ASC, RBRVS, etc.) and related standards
- Knowledge on Durable Medical Equipment Medicare policies
- Determine acceptability of evidence submitted and necessity for additional review
- Refer complex claims when appropriate
- Resolve claim issues
- Maintain departmental standards for quality and production goals
- Ability to interpret and apply written guidelines applicable to claim adjudication
- Maintain compliance with claim routing procedures
- Maintain compliance with inventory control procedures
- Communicate system and/or specific claim issues in a timely manner to Department Supervisor
- Analyze the correct way for avoiding the excess payment
- Process nonparticipant provider claims in a timely manner as CMS rule and company policies and procedures
- Evaluate and process claims issues sent from Appeals and Grievance Department
- Identify discrepancies and outstanding issues and secure additional information while investigating within the time frames establish by policy and procedures
- Communicate with Health Services Department for pre-certifications process and with Finance Department for claims payment
- Process reimbursement of patients
- Knowledge of the QicLink system
- Perform other duties as required by supervisor.
Billing Manager
Caribe Medical Supply, Inc.
01.2002 - 01.2008
- Supervise and assist billing personnel
- Perform clerical duties and maintained an efficient and highly organized Medical Record Department
- Accurately applied payments to patient accounts
- Researched and resolved incorrect payments
- Ensure exact billing and resolved claims denials and medical-necessity issuances
- EOB rejections, and other issues with outstanding accounts
- Reviewed billing edits and provided insurance providers with corrected information
- Provided tenacious follow-up to ensure proper payments were fully collected
- Greeted clients in a professional and courteous manner
- Received Rx and enter data in the system (Fastrack)
- Provided ongoing training to staff on intricacies of insurance submissions, codes and intake procedures to minimize rejections for referral related reasons
- Strong ability to interact and communicate with people over the telephone, often in stressful situations
- In-depth knowledge of medical billing procedures-submission of insurance claims, Medicare, HMOs, and other private insurance carriers
- Excellence knowledge of insurances Appeal process
- Participate in development of organization procedures and update of forms and manuals
- Research and respond by telephone and in writing to patient inquires regarding billing issues and problems
- Monitor unpaid claims, initiate tracers
- Post and reconcile payments to patient ledgers
- Balance daily batches and report; prepare income reports and statistics.
Education
Bachelor Degree - Business Administration, Accounting
Universidad Metropolitana
Bayamón, PR 01.2009 - 05.2012
Associate Degree - Pharmacy Technician
National College
Bayamón, PR 01.2001 - 05.2003
Skills
- Fully bilingual
- Responsible
- Active
- Committed
- Self-starting
- Excellent interpersonal skills necessary to consistently interact with patients, families, visitors and staff in courteous manner; and to maintain positive working relationships
- Attention to detail
- Ability to work to deadlines
- Communicate clearly and concisely, both verbally and in writing to individuals of diverse backgrounds
- Perform in a fast-paced environment and work under pressure
- Establish and maintain interpersonal relationships internally/externally and utilize skills by; coaching and motivating staff, handling conflict resolution, implementing project or new programs/initiatives and collaborating with other departmental subject matter experts
- Demonstrate knowledge of applicable claims processes (eg, end-to-end claims cycle, autoadjudication, manual work processes, payment methodologies, rework/adjustment processes)
- Terminology, CPT, revenue codes, ICD10, HCPCS codes as it relates to claims processing adjudication Core claims processing systems and healthcare authorization systems
- Knowledge in Medicare reimbursement methodology (ex APC, ASC, RBRVS, etc) and related standards
- Utilize and access computer and appropriate software (eg, Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems (eg, MedhoK, OnBase, SQL, PMHS System and QNXT System) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position
- Encourage and utilize suggestions and new ideas
- Providers Satisfaction
- Troubleshoot claims adjudication problem areas
- Comprehend and interpret provider contracts
- Organize, plan and prioritize work activities, possess analytical and problem-solving skills
- Financial Budgeting
- Team Leadership
Training
- Medicare Workshops
- Workshops of Accreditation Standards Quality Improvement
- HIPPA Compliance training and workshops
- ICD-10 workshop
- Training billing and coding professional, institutional and ambulance services
Certification
Revenue Cycle Certification
Accomplishments
Achieved and exceeded the goal with the recovery of 20 millions in 2024 with accuracy and efficiency.
Timeline
Financial Recovery Supervisor
MSO OF PUERTO RICO-MMM HEALTHCARE
01.2018 - 01.2021
Collection Department Supervisor
De Jesús & Matos Medical Imaging
01.2014 - 01.2018
Administrative
Family Business
01.2010 - 01.2014
Claim Analyst II
Medical Card System, Inc.
01.2009 - 01.2010
Bachelor Degree - Business Administration, Accounting
Universidad Metropolitana
01.2009 - 05.2012
Claim Analyst
Salud Dorada con Medicare
01.2008 - 01.2009
Billing Manager
Caribe Medical Supply, Inc.
01.2002 - 01.2008
Associate Degree - Pharmacy Technician
National College
01.2001 - 05.2003
Manager I-Financial Recovery Ops
MSO OF PUERTO RICO-MMM HEALTHCARE
1 2021 - Current
Revenue Cycle Certification
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