Megan Smith
Benefits Specialist @The Judge Group
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WORK HISTORY
Benefits Specialist @The Judge Group
Responsible for process Specialists Adjustments, Replacements, Refunds, and Appeals Queues, Group queues content at 98% average, within 30 days of receipt. Review and process pended claims, within 5 days of initial review Respond to internal inquiries within 48 hours of receipt. Review, investigate and provide accurate and efficient follow-up. Ensure Special Projects are completed accurately, in a timely and efficient manner. Participates in system testing and reviews for upgrades/implementation Identify and communicate to team, leadership, and other departments (if applicable), trends related to appeals processing, not yet addressed in a desk level procedure or identified by another team member. Collaborate with Provider Relations team to educate providers regarding trends identified in appeals process. Analyze potential system configuration setup issues when trending appeals to determine if modifications must be made to increase the automation of the adjudication flow. Investigate and research Texas Medicaid regulatory requirements for various payment methodologies for hospitals, physicians, home health agencies, CORFs, etc, to apply to various claim scenarios where system cannot be automated. Utilize expertise with federal NCCI edits, MUE edits, etc, to determine if providers are billing inappropriately or fraudulently. Refer potential fraud activity to FWA unit for further investigation Evaluate the appropriateness of code bundling, un-bundling, and addition of modifiers by provider to determine if higher level of payment is warranted or if provider is upcoding. Refers trends of inappropriate activity for further data analytics for potential fraud. Process and coordinate claims identified by the Fraud, Waste & Abuse (FWA) department for retraction and/or reprocessing. Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt.
EDUCATION
Intelli charter high sc
Diploma, General Studies
Rio Salado College
Associate of Science (A.S.), Counseling Psychology
Grand Canyon University
Bachelor of Business, Business, Management, Marketing, and Related Support Services
Artistic Beauty College
Cosmetology, Cosmetology, Barber/Styling, and Nail Instructor
ABOUT MEGAN SMITH
I am the Creator/Owner of Your Defining Moment. I am a Certified Life Coach/Author/Blogger that helps women unapologetically become the best version of themselves. I specialize in the areas of: Finding their purpose Obtaining Emotional Freedom and Emotional Balance Life Growth (spiritually, communication, career, self-esteem & confidence) Heart & Soul (Improving your relationship with yourself and others) Mindset shifting (Empowering you to be your best you) The purpose of my practice is to help others embrace the emotions and work through the process of becoming free. I am authentic and have a passion for helping others find true fulfillment by using new and different techniques that encourage new ways of thinking, attaining balance and discovering what\'s already there and by my clients being themselves unapologetically. I believe that we always continue to seek new ways to be limitless, innovative, inspired, finding the courage and passion to dream big but achieve bigger. Contact info: i•••@yourdefiningmomentnow.com (71••••••74 Website: yourdefiningmomentnow.com Facebook:
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