Medical Quality Control

Pedro Biskupovic

**** ** *** ***. *** ****,

Miami, FL 33129

786-***-**** ***********@*****.***

OBJECTIVE

Seeking a challenging opportunity where I will be able to utilize my experience and education while contributing to

the organization's overall success.

SUMMARY OF QUALIFICATIONS

• Over 13 years of experience in the health insurance industry and international travel assistance.

• Extensive knowledge of medical claims processing, auditing and medical terminology ICD-9, ICD-10, CPT,

HCPCS, DRG codes, understanding of HIPPA regulations.

• Extremely productive and reliable in high stress environment.

• Good eye for detail, well organized, skilled in setting priorities.

• Skilled and thorough in analyzing problem situations and finding creative solutions.

• Strong interpersonal, organizational, communication and leadership skills.

• Able to work independently and in a team environment.

• Computer literate in Windows, Microsoft Word, Excel and Power Point.

• Fluent in English and Spanish (verbal and written), knowledge of Portuguese

EXPERIENCE

1999-2012

Federal Assist Miami, FL

Medical Claims Supervisor

• Supervised daily operations activities for the international claims department.

• Monitored billing activities, performance management, production standards and quality of results.

• Determined accuracy of claims adjudication to include contract interpretation, benefit limitations, correct

coding, edited and determined if claims were paid in accordance with all industry guidelines and regulations.

• Audited and re-priced large hospital claims and implemented quality control on a daily basis.

• Reviewed and responded to claim appeals and grievances.

• Took responsibility for interviewing, training and motivating Claim Examiners.

• Gathered, interpreted and analyzed reports to provide recommendations to Management.

• Investigated and recovered subrogation cases.

• Negotiated prompt payment discounts directly with providers all over the USA, Canada and Puerto Rico.

• Processed and billed cost containment cases for several international clients.

• Worked directly with the finance department to implement wire transfers were properly applied to each

account.

• Managed client relations with members, providers and cost containment networks in charge of obtaining

discounts.

• Worked directly with the medical case management to review high profile cases and large hospital claims.

Andy Frain Services Miami, FL 1994-1998

Security officer at Brickell Bay Village

• Ensured that only authorized persons were permitted access to closed or restricted areas.

• Monitored alarm systems and electronic surveillance equipment and responded to locally activated fire,

burglary or other alarms.

• Wrote daily activity, incident and non-employee injury reports.

Quantech Inc. Santiago, Chile 1991-1993

Geophysical Field Supervisor

• Supervised field operations of geophysical surveys.

• Prepared daily reports of measurements from electric electrodes measuring location of minerals in the field.

• Supervised three people in the field.

Chase Manhattan Bank Manhattan, NY 1988-1990

Securities Processor

• Setup and maintained databases and client files, processed and confirmed trades, researched errors, failures,

and inquiries.

• General Data Entry and basic accounting (book keeping).

EDUCATION

Florida International University Miami, FL

1997-2000

Bachelor of Business Administration

Miami Dade College Miami, FL 1995-1997

Associate in Arts degree

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