Lamesha Ridgeway
Chicago
Summary
Dynamic professional recognized for exceptional communication skills and a proven ability to manage multiple high-priority tasks effectively. Detail-oriented with a strong track record in creating, reviewing, and training on comprehensive process documentation, ensuring clarity and compliance at all levels. Expertise in the records management life cycle, encompassing both paper and digital content, drives efficient operations and adherence to industry standards. A strong collaborator adept at building lasting relationships with diverse teams while quickly mastering system functionalities to enhance support and service delivery.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Claims Reimbursement Specialist
HCSC - Blue Cross Blue Shield of Illinois
08.2024 - Current
- Analyzed and audited expense reports for accuracy and compliance
- Verified documents to ensure reimbursement eligibility.
- Processed insurance claims quickly and accurately, reducing overall errors by 36%
- Ensured timely resolution of claim discrepancies, achieving a 99% rate of deadline compliance.
- Partnered with various departments to tackle reimbursement issues.
- Developed and implemented reimbursement policies and procedure
- Ensuring that the records include sufficient evidence to support the billed services, such as physician's orders, progress notes, or other relevant documentation.
- Provided training and guidance to employees on reimbursement processes
- Verifying that the codes used to bill for the services accurately reflect the procedures performed.
- Ensuring that the diagnosis codes used align with the medical documentation and the procedures performed.
Associate Project Delivery Specialist
HCSC - Blue Cross Blue Shield of Illinois
01.2020 - 08.2024
- Navigated complex challenges adeptly by adapting strategies based on evolving circumstances.
- Ensured regulatory compliance by keeping abreast of industry-specific guidelines and incorporating them into every aspect of the project.
- Developed customized project management tools for improved organization and monitoring of tasks.
- Managed budgets effectively, consistently delivering projects within allocated financial resources.
- Actively participated in negotiations with vendors and suppliers, securing favorable terms that enhanced overall project value.
- Facilitated stakeholder engagement through regular status updates and progress reports, fostering transparency and trust.
- Assisted with day-to-day operations, working efficiently and productively with all team members.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
Work Comp Claim Assistant
Horwitz Horwitz & Associates
10.2019 - 06.2021
- Focused on managing claims related to Illinois Work Comp.
- Works closely with employees to ensure that all relevant completed medical documentation is submitted for timely review
- Report new work injuries to Third Party Administrator
- Monitor claim handling activity by Third Party Administrator
- Establish and maintain internal electronic files, including notes, records, statements, and correspondence
- Recognized and removed barriers to assure high quality claims outcome.
- Reviewed injury circumstances to analyze merit and estimate financial impact.
- Actively managed over 40 open workers compensation claims, including directing medical treatment and distributing compensation benefits.
- Successfully conducted quarterly claims reviews with all clients to keep them abreast of their open claims and claim strategies.
- Maintained high level of confidentiality in handling clients' medical claims, including knowledge of HIPPA
- Coordinated claims case management with physicians and other health care professionals.
Medicaid Follow-up Rep
Northwestern Memorial Hospital
06.2020 - 12.2020
- Contacted and worked with Medicaid with processing and verifying claims
- Addressed claim denials and payer requirements to ensure corrective action.
- Process more than 60-70 healthcare claims per day.
- Validated benefits to facilitate authorization processes for continued treatment.
- Performs account research with internal and/or external resources via phone and payer websites to determine status of the account with the expected result of obtaining payment of the account.
- Verified and/or updates insurance and demographic information for accuracy to resolve barriers in receiving payment of the account.
- Responsible for billing, collecting, post payment review, credit balances and correspondence functions of all aged government, non-government, and patient accounts.
Appeals/Denials Specialist
Medix Temp Agency/UC Medicine Ingalls Memorial Hospital
12.2018 - 10.2019
- Filed/recommended adjustments where appropriate for medical necessity qualifications, duplicate, contractual, and past filing claim and appeals deadlines.
- Conducted analysis/research and led dispute resolutions in appeals processes.
- Prepare necessary paperwork for patient appeals with insurance.
- File appeals and reconsideration disputes with insurance companies.
- File appeals to insurances for reconsideration.
Medicare/Medicaid- Biller
Healthcare Support Temp Agency/ Conifer Health Solutions
06.2018 - 09.2018
- Maintained accurate medical records, applied ICD-10 coding, obtained pre-authorizations and referrals and verified eligibility and benefits
- Submitted insurance claims to Medicaid and Medicare and performed follow-ups on unremitted claims within the billing cycle period
- Translate patient information into code, enter medical records into the EHR database, and ensure compliance with HIPAA regulations and data protection laws for confidential information
- Coordinate insurance reimbursement to care providers, process payments from patients and insurers, ensure accuracy, and resolve billing errors
Medicaid/Managed Care Biller/Follow-Up
Medix Temp Agency/UC Medicine Ingalls Memorial Hospital
10.2017 - 06.2018
- Audited and researched patient accounts to resolve credits and undistributed activity.
- Posted Medicaid/ Managed Care payer payments to patient accounts and ensured payments were calculated accurately.
- Ensured compliance with procedures in patient account reviews to secure prompt insurance company payments.
- Read and understand EOB denials and Deductible/Co-Insurance EOB's, adjust and document detailed information into patient accounts.
- Worked with different departments to ensure fiscal responsibility on patient accounts, resolve charge errors and coding corrections.
Medicaid/Managed Care Biller/Follow-Up
Medix Temp Agency/UC Medicine Ingalls Memorial Hospital
10.2017 - 06.2018
- Resolved all credits and undistributed activity assigned through daily distributions and reports by auditing and thoroughly researching patient accounts.
- Posted Medicaid/ Managed Care payer payments to patient accounts and ensured payments were calculated accurately.
- Review patient accounts to ensure that the proper protocol is followed to obtain timely payment from insurance companies.
- Read and understand EOB denials and Deductible/Co-Insurance EOB's, adjust and document detailed information into patient accounts.
- Worked with different departments to ensure fiscal responsibility on patient accounts, resolve charge errors and coding corrections.
Education
M.H.A - Health Administration
National-Louis University
Chicago, IL12.2021
M.A. - Public Administration
National- Louis University
Chicago, IL08.2012
B.A. - Business Administration
Roosevelt University
Chicago, IL12.2010
Skills
- Claims and Revenue Analyst
- System-based Practice
- Claims processing
- Medical billing
- Teamwork and collaboration
- Customer service
- Problem-solving
- Time management
- Attention to detail
- Multitasking
- Reliability
- Excellent communication
- Critical thinking
- Organizational skills
- Active listening
- Decision-making
- Medical terminology
- Insurance claim forms review
- Insurance coverage verification
- Denied claims identification
Certification
- Medical Billing and Coding (CCS Certification), DeVry University, 2022-11-01- Present
Timeline
Claims Reimbursement Specialist
HCSC - Blue Cross Blue Shield of Illinois
08.2024 - Current
Medicaid Follow-up Rep
Northwestern Memorial Hospital
06.2020 - 12.2020
Associate Project Delivery Specialist
HCSC - Blue Cross Blue Shield of Illinois
01.2020 - 08.2024
Work Comp Claim Assistant
Horwitz Horwitz & Associates
10.2019 - 06.2021
Appeals/Denials Specialist
Medix Temp Agency/UC Medicine Ingalls Memorial Hospital
12.2018 - 10.2019
Medicare/Medicaid- Biller
Healthcare Support Temp Agency/ Conifer Health Solutions
06.2018 - 09.2018
Medicaid/Managed Care Biller/Follow-Up
Medix Temp Agency/UC Medicine Ingalls Memorial Hospital
10.2017 - 06.2018
Medicaid/Managed Care Biller/Follow-Up
Medix Temp Agency/UC Medicine Ingalls Memorial Hospital
10.2017 - 06.2018
M.H.A - Health Administration
National-Louis University
M.A. - Public Administration
National- Louis University
B.A. - Business Administration
Roosevelt University
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