Medical Insurance

LUISA B. NAPOLES

P.O. Box **-

****

Hialeah, Fl. 33012

Cell: 305-

***-****

Email: *******@*********.***

CAREER OBJECTIVE HISTORY

To obtain a challenging position in the area of health care where I can

share my communication, insurance collections, administrative and technical

skills as well as.

EMPLOYMENT HISTORY

BUPA LATIN AMERICA

Miami, Florida

2009 to Present Medical Claims Processor

. Processing 20 claims per week submitted by the Mexico region

policyholders. My duties entailed verification of each individual

receipt/bills submitted by the policyholders for reimbursement. The

receipts vary according to claim and the amount of bills received. For

example: Hospital, Doctors, Maternity, Endoscopic Examinations,

Specialists, Pediatric and adult. Each claim is scanned in iSynergy

Imaging system and assigned to each individual processor. The claims

are registered via the PSI medical system for processing. Each bill

is analyzed and processed according to policy provisions. Payments

are sent to policyholder via Check, Bank Transfer or applied to their

Premium Payment. A letter is sent with the Explanation of Benefits

(EOB) explaining in detail my decision for claim denial or

reimbursement.

. Maintain Quality Control of 90% or above per claim.

. Verify the policyholder's insurance is still active with BUPA.

. Interact extensively with the Account Managers and Agents by

responding to their e-mails within 24 to 48 hrs for concerns when a

bill is denied.

. Interact with in-house physicians regarding medical doubts concerning

a procedure or diagnosis and whether or not to cover for

reimbursement.

. Interact, Assist and Support my team in case questions arise

concerning difficult cases.

Training received:

PSI Medical System

iSynergy Imaging System

BUPA International Policies

2000 - 2009 UNIVERSITY OF MIAMI MEDICAL CAMPUS

DEPARTMENT OF SURGERY

Miami, Florida

Senior Collection Specialist/Adult and Pediatric

Thoracic-Cardiovascular Division and Heart/Lung Transplants

. Responsible for handling collections for various Thoracic-

Cardiovascular Surgeons for reimbursement of claims.

. Follow-up from A/R aging report by prioritizing oldest accounts with

high balances (over 120 days) by insurance carriers as well as other

reports consisting of Operating Room monthly report

. Request in-patient hospital records for surgical procedures and out-

patient medical records to avoid denial of claims.

. Adjustments, write-offs and refund requests.

. Review Explanation of Benefits (EOMB's): Medicare, Medicaid, HMO's and

Commercial insurances for denials including bundled procedures and

percentage of payments according to contracted rates.

. Request documentation and letters of medical necessity for medical

review or appeals.

. Verify patient demographics, eligibility by calling the insurance on

file.

. Answer and resolve all correspondence pertaining to denials.

. Participate in Compliance Programs or educational programs offered by

the University.

1998 - 2000 RIGHT CHOICE MANAGEMENT

MOUNT SINAI MEDICAL CENTER

Miami Beach, Florida

Physician Billing Department/Collections Representative I

. Responsible for the Medicare Unit collections for various physicians

in all groups for reimbursement of claims in compliance with the

Federal Regulations according to CPT-4 Procedural Coding Book and the

ICD-9 CM classification system.

. Respond to daily inquiries by insurance companies and patient

correspondence.

. Follow-up from aging report by prioritizing oldest accounts with high

balances (over 120 days) by insurance carrier.

. Request in-patient/out-patient hospital or office records for review.

. Prepare adjustments, write-offs, refund requests and transfer of

funds.

. Participate in Mount Sinai's Corporate Compliance Programs "Code of

Excellence" and attend Seminars or educational programs offered by the

department in order to maintain an awareness of laws and regulations

affecting the department.

EDUCATION

January 2006 - October 2006 - Certificate in Healthcare Management

University of Miami, Koubek Center.

University of Miami/Medical Campus - Blue Cross/Blue Shield Virtual

Office Training (2000)

University of Miami/Medical Campus - Compliance Training Dept of Surgery

(December 2000 to November 2006)

University of Miami/Medical Campus - Health Insurance Course-105 (2001)

Mount Sinai Medical Center - Comprehensive Compliance Training (1999)

U.S. Seminar Corporation (1999)

Right Choice Management/Mount Sinai - Collector's Training (1999)

Right Choice Management/Mount Sinai - The Med Ed Company Service Care

Seminar - Patient Satisfaction/Service Excellence (1999)

PERSONAL

U.S. Citizen - Excellent Health

Fluent in English and Spanish

References available upon request

Contact this candidate