NANCI AGUILAR

714-***-****

**** ******* **., ******, **. 92881

Dell Inc 4/27/2015 to date

Remote Claims Adjuster

Remote in on Dell website and analyze claims to verify the correct fee was applied and override claim coding errors via SOP and Knowledge Library.

Adjust claims for UHC via Diamond processing system.

Log production

Participate in round robin calls.

P.P.M.C. INC. 12/ 2013 – 1/2014

Claims Department Manager

Manage the workflow of claims to be processed and loading claims into the check write program daily.

Monitor department activity and generate production reports to audit production standards, quality and efficiency of claims department.

Maintain and manage daily turn-around time according to our Network provider contracts, Non Par providers, Medicare guidelines and ICE Compliance guidelines.

Review Quality Audit results and consult with staff to improve production and quality results.

Develop and maintain all staff schedules, insuring appropriate department coverage.

Produce and deliver workflow reports for examiners to complete daily.

Produce and deliver workflow reports for off shore office.

Create reports to be auto adjudicated for review of department standards, auditing recommendations and production.

Memorial Care Medical Foundation 2/2012 – 12/2013

Manager Claims Department

Direct and manage the claims department, including customer service, document control and auditing departments. Client satisfaction; assure team members are meeting and/or exceeding job. Use of QNXT system and in transition to Epic (Tapestry) systems. Extensive use of Word, Excel, Power-point, Office, Visio programs, Ingenix, and Encoder Pro.

Monitoring department activity and generating production reports to audit production standards, quality and efficiency of claims department.

Maintain and manage daily turn-around time according to our Network provider contracts, Non Par providers, Medicare guidelines and ICE Compliance guidelines.

Establish and measure production goals for all areas of claims department.

Review Quality Audit tracking/reporting (Financial and Procedural) for claims and registration and identify areas of improvement

Review Quality Audit results and consult with staff to improve production and quality results.

Create/maintain claims systems, letters and reports.

Responsible for the management of claims work EDI and Imagenet (scanned) coordination..

Develop/maintain staff schedules, follow personnel policies insuring appropriate workflow.

Hire and train staff. Complete all staff reviews in a timely and appropriate manner.

Set goals for production and QA for staff and monitor results.

Maintain MOOP files, assuring all appropriate patient liability has not exceeded the maximum.

Assist and lead in the creation and maintenance of the Policy and Procedure Manual

Create and maintain workflow charts.

Comply and enforce company policies and procedures as outlined in the Employee Handbook.

Perform special projects at the request of management.

Answer all correspondence promptly and maintain correspondence files.

Run and clear check write reports weekly.

Interact with other key departments and assist in projects as needed.

GALLOP AWARDS: 2013 Presidents award for most improved department and MemorialCare Presidents Club award.

Orange County Foundation for Medical Care - Orange, CA 2008-May 2011

TPA business from the Riverside Foundation for Medical Care aka Foundation

Administrative Services Inc. was purchased and the business transferred to Orange

Foundation Administrative Services Inc. – Riverside, CA

Riverside Foundation For Medical Care - Riverside, CA 2006-2008

Manager Claims Department

Direct and manage the claims department and Claims Team, Re-pricing Team, Customer Service Team, Provider File Team and Claim Support Team. Client’s satisfaction with operations. Assure team members are meeting and/or exceeding client expectations. Use of excel and Microsoft Word. Lots of interaction with clients, providers, members and staff. Oversee work issues within the department. Also work with the Provider Relations Department and MSI unit.

Monitor department activity and generating monthly reports to audit consistency, quality and efficiency of all aspects of claims department.

Manage Turn Around time according to our Network provider contracts, and OCFMC standards.

Establish and measure production goals for all areas of claims department.

Review Quality Audit tracking and reporting (Financial and Procedural) for claims and registration and identify areas of improvement

Review Quality Audit results and consult with staff to improve production and quality results.

Create/maintain claims systems, letters and reports.

Manage claims work EDI and paper flow coordination.

Monitor service to guarantee groups in regards to turn around and accuracy standards and quarterly report submissions.

Develop and maintain all staff schedules, follow all corporate personnel policies insuring appropriate workflow and telephone coverage.

Hire and train staff. Complete all staff reviews.

Set goals for production and QA for staff and monitor results. Communicate results to staff on a weekly basis.

Maintain client files, assuring that all appropriate information has been recorded.

Lead in the creation and maintenance of the Policy and Procedure Manual

Process claims in accordance with procedures and Industry standards.

Ensure the smooth operation of the entire claims department

Perform special projects at the request of management

Answer all correspondence promptly and maintain correspondence files

Document and respond to all Appeals for payment and Network contract issues.

Develop, implement and interpret current company policy and procedures

Interact with other key departments

Gather necessary documents for Credentialing of Network providers.

Reviews docs. for UM, refers Large Case Management diagnosis for review.

Run checks for provider payments

Post and process all refund checks, stop payment requests and voided checks.

Maintain the system for benefits updates, CPT codes, RBRVS and ICD9 codes

Maintain files, run reports and request reimbursements from Stop Loss Carriers.

Rewrite, simplify Plan Documents for Clients.

Participate in quarterly meetings with Clients and Benefit Review Boards.

Analyze reports for over utilization of plan benefits.

GBAS, AS400 AND El Dorado claims system experience at this job site. Claims system oversight and management.

Heller Associates Costa Mesa, CA 2001-2006

Insurance claims analyst-lead

Process medical/dental/vision insurance claims

Submit for review hospital claims over 10,000.00

Liaison for 50+ppo networks

Customer service

Mail room-reception relief

Return checks adjuster

Provider spread sheets to clients on refunded checks

Principle Portfolio Santa Ana, CA 1998-2001

Supervisor Data Entry Unit

Process mortgage assignments to be recorded in the county clerks office for legal transfer from one mortgage company to another

Interviewed and trained new hires.

Report monthly to clients assignments received/recorded per county and state.

Approved or denied time off.

Gave yearly evaluations and raises.

Notarized mortgage assignments to be recorded.

Notary public 2000-2004 notarized legal transfer of mortgage deeds as noted above.

Head/Neck Tumor Spec. - Orange, CA 1997

Office Administrator

Set up appointments for pvt practice.

Ran pvt practice office.

Verified insurance, pulled charts for appointments, printed super bills, billed ins, ordered x-rays, lab and surgeries.

County Of Orange - Orange, CA 1997

Probation Night Counselor

Supervised incarcerated minors

Detained/reprimanded incorrigible minors

Counseled minors on behavioral problems

O.C. Foundation For Medical Care Orange, CA 1980-1996

Insurance Claims Analyst

Process, analyze and examine claims for payment or denial on medical, dental, and vision claims for a third party administrator.

Certificates: Excel class “Beyond Basics”, “Employee Safety, Priacy and Security Training”, “Coaching, Counseling and Disciplinary Actions”, “Business Etiquette”, “Preventing Harassment in the workplace”, “Difficult Conversations”, “The Just Culture”

Education:

Cornelia Connelly SHCJ High School – Graduated

N.O.C.R.O.P – Trade School – 1 year - Graduated

Rancho Santiago College – Field of study: Psychology, Medical Terminology 1 year

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