Mayler L. Martinez

***** ** **** ***** #****

Miami Lakes, FL 33015

Cell Phone: 305-***-****

acvq8q@r.postjobfree.com

Objective:

Seeking for a challenging and rewarding position within a stable organization where my knowledge, educational background, professionalism and experience could be utilized.

Qualifications Highlights

• Microsoft Word, Excel, Power Point, Google Docs, Snipping Tool, Snagit, Outlook, Cerner, Power Chart, AS400, Care Cloud, NextGen, EDM Imaging, Invision/Signature, AdvantX, GDS Claims, Medisoft, and QNXT proficiency.

• Knowledge navigating all the available Health Insurance websites regarding patients’ eligibility, claims status, authorization/referrals. Availity, Emdeon, Medicaid and CMS.

• Ability to read and comprehend UB-04, HCFA 1500 forms, EOB interpretation.

• Medical terminology, CPT-4, ICD-9, ICD-10, Modifiers, HCPCS, Diagnoses Codes. Managed care regulations and contract language - (HIPPA Compliance).

• Fully Bilingual (English/Spanish) Ability to communicate verbally and in writing.

•Able to relate cooperatively and constructively with clients and co-workers.

•Ability to follow detailed written or verbal instructions - Resolves complex payment issues in a timely manner.

Employment History

Miami Children’s Hospital

August 2015 to June 28, 2016

Authorization/Referral Coordinator

•Submitted Authorizations Requests to the different Health Insurances (Medicaid/Commercial Plans) accordingly, vigorously followed and executed HIPAA Compliance. Responsible for coordinating cases forwarded to quality management. Developed and maintained positive customer/patient relations and coordinated with various functions within the hospital and outsource offices to ensure customer/patient requests were handled appropriately and in a timely manner.

•Determined benefit eligibility; provided authorization for, outpatient precertification, prior authorization, and post service requests. Insurance Verification, Scheduling and Patient Registration. •Liaison between Primary Care Physicians' offices(On campus and or off-campus); Specialists, DME Offices and several departments within the hospital, Patients’ Parents/Legal Guardians, Home agencies and Rehabilitation Services (Speech, Occupational and Physical Therapy) and DME Offices.

•Managed incoming calls, emails, faxes' requests and same day incoming authorization/referral requests from specialists’ offices and different departments within the hospital. Responded to telephone and written inquiries from clients and in-house departments.

•Cerner (PEDS, Power Chart, PM Office, Scheduling Book, Revenue Manager) AS400, Care Cloud, Emdeon, MedAssets usage on a daily basis in order to perform my duties. Cash Posting Insurance Payments, Credit Balances, Patient Refunds and Adjustments at Hospital’s Headquarter Office.

Venture Ambulatory Surgery Center

September 2013 to April 2015

Accounts Receivables Representative

•Payment Poster (Health Insurance, Patient Payments and Miscellaneous Accounts’ Payments.

•Collections - Medical Insurance & Patient Past Due Accounts

•Usage of AdvantX (An EMR Application) in a daily basis, which is an EMR Application

•Analyze patient accounts - review of health insurance contracts, documentation, in order to post payments. Interpreting/analyzing Explanation of Benefits (EOB) in order to handle Insurance Payment Posting.

•Process Patient and Insurance Refund Checks. Posting of Bad Debt Credit and Correction of Bad Debt Credit Write-offs, Patient Collections.

•Duplicate merging of patients’ accounts – MR navigation.

•Front desk experience, which implies strong patient registration experience, health insurance verification, scheduling, directing in-bound calls to the proper areas.

•Administrative duties including filing, copying, faxing

•Assisting with billing, insurance verification coordination, insurance/patient collection

•Answering multi-line telephone

•Performed other duties as assigned by supervisor

Health System One Medical Management

December 2009 to June 2013

Medical Claims Examiner II

•Handled Providers inbound and outbound phone calls pertaining to claims status

•Responded to e-mails and faxes pertaining to claims status

•Processing and adjudication of medical claims for accounts requiring multiple disciplines in claims processing – Utilizing GDS (An EMR Application).

•Verified claim information, pertaining to services rendered by reviewing existing referrals and or authorization, and clinical records on file.

•Verification of member eligibility at time of service - Data/Account Analysis.

•Entered claims information into the claims adjudication system – when applicable.

•Researched, reviewed and adjudicated pended claims.

•Validation of claims after completion of pre-processing, adjudicating and pricing of claims; corrected all system edits as a result of the 3 step claims process.

•Recognition of claims issues/problems, refers them to management and/or appropriate party, and assists in the review and implementation of resolution of prices facility claims- using established software and enters results of pricing into the claims adjudication system.

•Assurance of claims processed in accordance to member benefits, provider contact terms, network protocols, medical authorization and departmental guidelines.

•Maintained individual productivity reports on claims adjudication/Ability to read and comprehend an EOB. Evaluated COB, Adjustments, Take backs, and Appeals.

•Met quality standards established by Claims Department Management. Provided back up to the clerical staff, other claims examiners and claims customer service; performed other duties as assigned by management.

Wolfson Children’s Hospital

May 2008 to November 2009

Medical Support Clerk

•Patient Registration, Insurance Verification Coordinator, Medical Insurance Verification both on-line and on the phone -(Availity, UHC, Avmed, BCBS, Emdeon, and Humana Military-Tricare).

•Vast knowledge of HMO/PPO - Auth/Referral processes. Strong Medical Terminology (HCPCS, ICD-9, CPT), Patient check out process.

•Medicare/Medicaid Verification, Encoder Pro, RAD MD, Citrix, Epic.

•Scheduling, Collections, Cash Posting, Office Supply Inventory Coordinator, Preparation of Charts. Answering multi-line telephone

•Administrative duties including filing, copying, faxing.

Kelly Services (Blue Cross Blue Shield of FL)

August 2006 to March 2008

Data Analyst (Other Party Liability)

•Support Services for Blue Cross Blue Shield/Other Party Liability Department.

•Data Entry, Generating Accident Letters, Data base sheets, Cost containment, coordination of benefits, Workers' Compensation, subrogation and no-fault auto insurance. Good documentation skills, detail oriented, met deadlines.

•Recovered money where primary responsibility did not exist because of another group health plan or contractual exclusions.

•Customer Service (Outbound/Inbound phone calls), coding, and research.

Health System One Medical Management

February 2001 to April 2006

Enrollment Services Representative

•Processing Enrollment, Renewal, Termination, Reinstatement Applications; Auditing Eligibility Reports.

•Office mailings - weekly checks, flyers, newsletters, overnight packages, created and distributed enrollment packages to future and existing members.

•Responded to Members’ Insurance Benefit Questions by Mail or by Phone.

•Data entry of enrollment forms, handling past due accounts.

•Terminating, reinstating, and renewing such accounts according to company policy and guidelines.

•Member Service - Inbound/Outbound calls, data entry, sorting and distribution of mail to Enrollment, Medical, Marketing and Billing Department.

Education

Florida International University (FIU) – Current Student: Pursuing - Health Services Administration Bachelor Degree (BHSA).

Miami Dade College Medical and North Campus

Medical Lab Technician AS Degree – Miami Dade (Medical Campus).

AA Degree - Miami Dade College (North Campus).

References

Available upon request

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