Claims Manager, Supervisor, Rates Configuration

HENDERSON B. BERBERABE

**** *** ****, ******* ****, CA 91706 626-***-**** ******@*******.***

CAREER OBJECTIVE

To secure a Management position in Claims Adjudication leveraging strong customer service and relationship building skills while utilizing over 17 years in the Health Care industry including 5 years of supervisory background.

HIGHLIGHT OF QUALIFICATIONS

Hired as a Claims Supervisor with High Desert Medical Group and was promoted to Claims Manager in ninety (90) days

A sharp and well organized team player who is capable of handling multiple projects concurrently and manage staff at all levels

Broad and diversified experience in Claims Adjudication, Compliance

Knowledgeable of HMO, PPO network pricing methodologies including CMS 1500/UB04 claims

Strong analytical skills in the interpretation of benefits matrixes, contracts, Division of Financial Responsibilities, DRG, APC and ASC pricing programs

Familiarity with EZ Cap 6.5.1, IDX, MHC systems

PROFESSIONAL EXPERIENCE

MedPoint Management, MSO

Supervisor, Rates Configuration Woodland Hills, CA Jan ’15 to Present

Performs technical and analytical work to support the functional and reporting requirement of the Claims department. Maintaining an up-to-date knowledge of national and state wide code sets, standards and regulations pertaining to the handling of claims documents and will assist department heads in identifying, remediating and resolving issues interfering with the accurate and timely adjudication of claims. System set claims pricing in accordance with provider contracts via Fee Set Assignments.

High Desert Medical Group Lancaster, CA June’14 to Dec ‘14

Manager – Claims Department

Provides organizational and management support to the Company by assisting the Director of Claims with ensuring efficient and effective operations in the Claims Department

Supervise 23 employees to achieve and exceed business objectives.

Provides expertise and support to team in reviewing, researching, processing and adjusting claims.

Develops staff through performance management, goal setting, training, and effective employee relations.

Prepares employee evaluations by due date.

Care1st Health Plan Monterey Park, CA Aug ’10 to June ‘14

Lead - Claims Resolution Analyst

Supervise 15 employees, training, employee relations, timekeeping and review of policies and procedures.

PDR processing based upon contractual and/or Care1st agreements, involving the use of established payment methodologies, Division of Financial Responsibilities, applicable regulatory legislation, claim processing guidelines and company policies and procedures.

All’s Well Health Care Services (Agency) Nov ‘08 to Jul ‘10

c/o Arcadian Health Plan and Management Services San Dimas, CA 7/09 to 07/10

Claims Auditor (MSO) / Special Project Analyst

Supervision of Remote Processors concerning claims activities, errors and questions. Areas of review include, but are not limited to, Duplicate Payments, Contract Compliance, Authorizations, Eligibility, Coordination of Benefits, Claims Payment guidelines, Special Projects and Provider Dispute Resolution (Appeals).

c/o North American Medical Management Ontario, CA 11/08 to 5/09

Revenue Recovery Analyst

Analyze revenues and expenses following established procedure for data collections and analysis. These include, but not limited to capitation revenue, risk programs, specialty capitation, data mining and claims data

ATI Staffing Solutions (Agency)

c/o California Field Ironworkers Trust Funds Pasadena, CA Mar ‘08 to Oct ‘08

Claims Specialist / HIPAA Compliance Officer

Multi-task responsibility includes Claims Processing (Professional and Institutional), Appeals, Adjustments, Audits, Customer Service, and HIPAA Compliance

Physician Associates Pasadena, CA Sep ‘06 to May ‘07

Compliance Analyst

Conducts compliance related functions, including, but not limited to; regulatory research such as DHS, DMHC, CMS requirements, Managed Care, universal reporting, perform internal and external auditing and other administrative duties

Facey Medical Group Mission Hills, CA Feb ‘06 to Apr ‘06

Claims Supervisor

Assures a continuously improving workflow process, identifies needs, makes recommendations & implement changes.

Assigns, manages and handles special project delegated by Director or Senior Management

Audit and report individual and team quality/production performance, gives daily, weekly and monthly feedback to staff of eighteen (18) claim examiners

Healthcare Partners Medical Group Torrance, CA Mar ‘03 to Feb ‘06

Compliance Specialist – Compliance Quality Assurance Department (07/04 – 2/06)

Reporting to the Director of Claims Quality Assurance, assist claims quality assurance management with claims compliance and training department staff to ensure that department standards are met.

Performs quality audits to ensure processed claims are in compliance with claims processing guidelines and departmental policies and procedures

Conducts random Examiner audits, prepares statistical analysis, and recommends training needs

Contract and Fee Schedule Analyst – Configuration Department (03/04 – 07/04)

Obtain state mandated Medical Fee Schedules for comparisons to federal/Medicare rates, analyze contract values by state and region

Analyze fee schedule rules to determine how they relate to the organization’s billing payment processes.

EDUCATION

Bachelor of Arts in Economics, Minor in Mathematics – 1984; San Beda College, Manila, Philippines

Evaluated by International Education Research Foundation, Inc.

Law Studies (2 years)

United States Navy – 1986 to 1990; Long Beach, California

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