Medical Manager
Resume:
CAROLINA D. FONTIMAYOR
Halethorpe, MD 21227
Email: **************@*****.***
EDUCATION
Medical Physician 1972 UERMMC
Manila, Philippines
Passed Philippines Physician’s Board Exam Nov. 1972
Passed ECFMG ( for foreign medical graduates) Exam July 1972
Bachelor of Science in Pre-MED University of Santo Thomas
Manila, Philippines
WORK HISTORY
ADVANTA GOVERNMENT SERVICES, LLC
Senior Medical Analyst 7/2012-1/13/2014
Primary Duties: Perform various types of medical record review by specific contracts. Performed first level of appeals from providers requesting a re-determination of the claims denied by RAC (Recovery Audit Contractors). Complete review of cases for medical necessity of services in accordance with guideline and regulations. Provided a fair and impartial decision. Wrote clear and concise letters that support determination made. Applied approved state and national criteria in determining medical necessity for healthcare services. Participated in special projects and perform other duties as assigned.
ADVANTA GOVERNMENT SERVICES, LLC
Senior Case Manager 11/19/2005-June 2012
Primary Duties: Review records/proposals submitted by different parties relating to a worker’s compensation injury for the purpose of assessing whether future medical expenses have been estimated appropriately to cover all future medical expenses associated with the work injury, re-cost and verify submitted costs, write a recommendation and submit to the centers for Medicare and Medicaid services (CMS) for them to make a determination on whether to accept, reject or counter the medicare re-aside (MSA) amount.
ADVANCED MED ( CSC COMPANY ) 9/2002-6/2005
Clinical Supervisor
Primary Duties: Serves as supervisor to abstractors providing advice, consultation and technical assistance. Answers abtractor’s questions on the vening shift/ Reviews the work of abstractors for accuracy and completeness. Assists the WLA in review of abstractors performance and interpretation of review findings. Assist the WLA in review of abstractors performance and interpretation of review findings. Assists the WLA and training staff in identifying abstractors training needs to enhance accuracy and production. Provides weekend coverage as scheduled.
ADVANCED MED ( DYNA CORP COMPANY) 3/1999-8/2002
ADJUDICATOR
Primary Duties: Serves as support staff to the Clinical Supervisory staff in performing adjudication on Intra-CDAC and Inter-CDAC IQCs. Adjudicates mismatches between original and reinstruction’s and creates gold standard cases for specified modules. Ensures accuracy and reliability of the clinical data collected by the abstractors by providing immediate feedback to the abstractors based on the results of adjudication. Helps Identify problems areas in abstraction and misinterpretation of guidelines. Identifies abstractors strengths and weaknesses and recommends training needs. Assist in streamlining the process to approve records for troubleshooting. Answer abstractor questions regarding specific findings in IWC charts. Offers strategies for improving date quality. Attends IQC meetings and training sessions as scheduled.
FMAS Corporation 10/1997-2/1999
ABSTRACTOR
Primary Duties: Reviews medical records for the purpose of abstracting medical data and enters information into an electronic database. Attends training sessions as scheduled. Actively participates in IQC meetings. Meets productions and data quality standards. Completes WBS on daily basis.
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