Healthcare Medical Claims

**** ****** **. *** *******, CA *****

Mobile: 323-***-****

**********@*****.***

NORA CUEVAS

OBJECTIVE

To obtain a position within the medical field that is challenging and contributes to my daily knowledge and growth as a medical professional.

SKILLS &

ABILITIES

Formulated policies and procedures

Willing to try new approaches

Effective in short-term action and long-range planning Ability to coordinate, prioritize and complete projects in a timely manner Ability to create forms, database

EXPERIENCE Licensed Realtor

Remy Castro Realty Estate & Broker 2007 - present

Involved in the sale and purchase of Commercial and Residential Real Estate Properties. Helping clients understand the Real Estate market and how to invest wisely in a complex market.

Corporate Auditor

Longwood Management Skilled Nursing Care Facilities 2001-2006 Responsible for auditing trust accounts of residents in Skilled Nursing Facilities and in Board and Care Facilities. Audited admission files of residents in compliance with established corporate policies and procedures as well as State's financial guidelines. Conducted monthly in-service to Business Managers and Administrators on the Federal and State compliance guidelines. Conducted presentations to Corporate Management on process improvement and streamlining. Assisted Business Managers and Billers in collecting outstanding accounts from Insurance companies, Medicare and Medi-Cal. Provided feedback to corporate management with regards to root cause and suggested process improvement measures to ensure efficiency of managing and handling of residents' trust accounts. System Analyst

Meridian Health HPA 1999-2000

Responsible for auditing fee schedules for contracting and non-contracting hospitals, PCPs and home health care facilities. Conducted regular in-service to department personnel on contract updates. Made presentations to management on proposed process improvement and changes to workflow. Audited division of financial responsibility (DOFR) as well as risk pools. Set up and loaded provider EDUCATION

LICENSES

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contracts in the claim system. Prepared required reports to track and trend departmental performance for compliance.

Contract Analyst/Claim Auditor/Claim Examiner 1997-1999 Prudential Health Insurance

Review provider contracts for approval. Download contract into the system. Audit medical claims for finalization. Process hospital bills, doctors bill and any provider's claims.

Customer Service Representative

Great West Life Health Insurance 1990-1997

Responsibilities include responding to telephone queries regarding claim status, unpaid claims, benefit reductions, service denials, contract and discounts. Verified member eligibility and benefits to members and providers. Initiate pre-certification for inpatient confinements, outpatient surgeries and procedures. Responded to benefit and claim queries by Account Managers and Benefit Administrators. Processed and adjusted medical, dental and vision claims. Customer Service Representative/Adjustment Specialist Pacific Mutual Health insurance 1985-1990

Responsibilities include processing and adjusting medical, dental and vision claims. Adjusted claims incorrectly processed and provided feedback to claims examiners. Responded to queries by members and providers on claim status, benefit reductions, service denials, contract discounts and eligibility. Initiated pre- certification of outpatient surgeries and inpatient admissions. PHILIPPINE UNIVERSITY

LICENSED LIFE AND HEALTH INSURANCE

LICENSED REAL ESTATE AGENT

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