RCM Billing Manager | Behavioral Health | ABA Therapy
Metro Manila
I have 8 years of experience in U.S. healthcare, including 3 years specializing in ABA and behavioral health revenue cycle management. My expertise includes end-to-end ABA billing and claims management, claims follow-up, complex denial resolution and appeals, payer communications, and working with multiple payers such as Commercial, Medicaid, TRICARE, and CHAMPVA across multiple states. I currently work as an RCM Manager for ABA services, where I also own the provider onboarding process and making sure new providers are fully set up and ready for billing before being handed off to the billing team. I also help support credentialing and handle complex billing issues and escalations within the team. I’m particularly interested in opportunities where I can apply my hands-on ABA billing and RCM expertise while continuing to contribute at a leadership level.
Raven Health, LLC, full_time
Jan 2025 to Present
• Manage revenue cycle operations for ABA services across multiple states and payers, with a strong focus on billing accuracy, clean claims, denial prevention, and timely reimbursement. • Own the full provider onboarding process, ensuring new providers are properly set up, their information is complete and accurate, and all billing-related requirements are in place before handoff to the billing team. • Support the credentialing process for new providers and coordinate follow-ups to help ensure providers are properly established with applicable payers. • Oversee end-to-end ABA billing and claims management, including claim submission, payer follow-up, claim status inquiries, payment issues, and resolution of outstanding accounts. • Handle and troubleshoot complex ABA claim denials and billing issues, identifying root causes such as authorization requirements, credentialing or enrollment issues, eligibility, modifiers, payer-specific billing rules, and provider information discrepancies. • Manage denial resolution, reconsiderations, and appeals, working directly with payers when additional investigation, documentation, or manual review is required. • Provide support and escalation for the billing team on complex claims and denial cases, helping determine the appropriate resolution and next steps. • Perform hands-on OON (out-of-network) billing, including payer-specific requirements and claim handling for providers who are not participating with certain plans. • Work with multiple payer types, including Commercial, Medicaid, TRICARE, and CHAMPVA, while navigating different state and payer-specific ABA billing requirements. • Help establish and maintain effective provider onboarding workflows, processes, and tracking systems to prevent gaps or oversights that could affect billing and reimbursement. • Collaborate with providers, billing staff, credentialing teams, and payers to resolve issues and ensure a smooth transition from provider onboarding to successful claim submission. • Maintain a strong focus on billing accuracy, clean claims, denial prevention, and overall revenue cycle performance within a multi-state ABA environment. Core Expertise: ABA RCM | Medical Billing | Claims Submission & Follow-Up | Denials & Appeals | OON Billing | Provider Onboarding | Credentialing Support | Payer Communication | Multi-State ABA Billing | Commercial & Medicaid | TRICARE | CHAMPVA | Complex Claim Resolution
Raven Health, LLC, full_time
Jun 2024 to Jan 2025
• Experienced U.S. Healthcare Revenue Cycle Management professional with 8 years of experience in medical billing, claims management, A/R, denials and appeals, payer follow-up, and reimbursement resolution. • Manage end-to-end medical billing and RCM processes, including claim preparation, submission, follow-up, payment resolution, and A/R management. • Review claims for billing accuracy, including CPT/HCPCS codes, modifiers, insurance information, provider details, and payer-specific requirements. • Handle complex claim denials, rejections, underpayments, and unpaid claims by identifying root causes and coordinating appropriate corrections, reconsiderations, appeals, and payer escalations. • Perform insurance eligibility and benefits verification, primary and secondary insurance review, coordination of benefits (COB), and resolution of insurance-related claim issues. • Experienced in both in-network and out-of-network (OON) billing, payer communication, claim research, and reimbursement follow-up. • Work directly with insurance payers to investigate claim issues, request reprocessing, clarify billing requirements, and resolve outstanding accounts. • Handle credit balances, refunds, adjustments, payment discrepancies, and account reconciliation. • Experienced with CMS-1500 and UB-04 claims and multiple healthcare/RCM systems, including Waystar, HealthQuest McKesson, MicroMD, Meditech, Epic, and Inovalon. • Provide support and escalation assistance for complex billing and denial cases, with a strong focus on accuracy, clean claims, timely reimbursement, and effective revenue cycle management. Core Expertise: Medical Billing | RCM | Claims Management | A/R | Denials & Appeals | OON Billing | Payer Follow-Up | Eligibility & Benefits | COB | CPT/HCPCS | Modifiers | CMS-1500 | UB-04 | Payment Reconciliation | Complex Claim Resolution
PayrHealth, LLC, contract
Jun 2023 to May 2024
Medical Claims Representative - Prepared and submitted clean medical claims to third-party payers through electronic and paper submission methods. - Reviewed and resolved claim-related issues to support timely and accurate reimbursement. - Managed insurance follow-up and denial resolution, including researching claim status and payer requirements. - Prepared and submitted adjusted, corrected, and rebilled claims as needed. - Posted payment adjustments, transfers of responsibility, refunds, and other account adjustments accurately. - Investigated claim discrepancies and communicated billing issues or delays within the revenue cycle to the appropriate Advanced Biller. - Assisted with patient billing inquiries and claim-related questions. - Maintained strict confidentiality and compliance with HIPAA guidelines and regulations. - Collaborated with internal billing teams to help ensure claims were processed accurately and efficiently throughout the revenue cycle.
Optum Global Solutions, Inc, full_time
Jan 2018 to Jun 2023
- Conducted prospective and retrospective overpayment reviews to identify payment discrepancies and ensure claims were paid accurately. - Analyzed contractual requirements to determine payer overpayments and amounts owed. - Researched and verified claims to identify payment and overpayment issues. - Collaborated with providers and payers to investigate and resolve payment accuracy concerns. - Reviewed COB and primary vs. secondary payer responsibilities to ensure correct payment allocation. - Updated claims systems to reflect accurate payment levels and appropriate payer responsibility. - Supported payment integrity and revenue cycle operations through detailed claims research and account analysis.