Claims s

OBJECTIVE

Experienced leader and knowledgeable medical claims processor with a strong background in claim processing, review, and resolution. Motivated and exemplary individual with over 20 years of experience looking to advance my skills and knowledge with a reputable company.

SKILLS &

ABILITIES

Advanced billing professional with a strong background in the healthcare industry. Skills and attributes include knowledge of medical terminology, ICD-9, ICD-10, CPT, HCPCS billing codes, experience with HMO'S, PPO'S, Managed Care and Government Programs. Proficient with various claims management software including but not limited to CareRadius Excel, PMMIS Facets, Remedy QXNT, MediSoft Medical Manager. PIF Tracker, Share Point

EXPERIENCE

Benefit Analysis 9/2023 – Present

Optum- Health Care Support Sacramento, CA

•Analyzing and coding renewal business, new business and system migration to complete analysis of benefit information and code into various systems.

•installed benefits to ensure claims are paid and benefits are quotes to the members

•Met very short deadlines and are required to have benefits built accurately in the system

Appeals and Grievances Coordinator 10/2020 – 9/2023

Molina Healthcare-Infinite Computer Solutions Phoenix, AZ

•Process/finalized appeals and grievances timely and within agreed-upon turnaround time.

•Exceptional customer service agent through effective listening and communication skills.

•Submission of verbal and written notification to members and providers utilizing appropriate software.

•Prepare appeal summaries, correspondence, and documents for tracking/trending data.

•Assist in the preparation of narratives, graphs, flowcharts, and ad hoc reports for presentations and audits.

CLAIMS AUDITOR ASSISTANT 08/2017 – 11/2020

Bardon Insurance Group Scottsdale, AZ

•Analyzed, researched, and compiled data to auditor for special projects.

•Provided administrative & management assistance and directed activities in office.

•Completed pre-audit specific claim submissions.

•Reviewed aggregate reports and entered into BIG's system.

•Reconcile TPA specific claim amounts vs Bardon's reimbursement amounts.

•Advised the Director of Claims of catastrophic/high dollar/possible aggregate claims.

•Created Plan documents and reports.

•Aggregated notifications into BIG's system, Young system, and UGAN system.

•Manually handled 2 system integrations.

CLAIMS REVIEWER 02/2016 – 08/2017

TriWest Healthcare Alliance Phoenix, AZ

Reviewed medical/surgical and behavioral health claims for inpatient and outpatient services.

Collaborated with claims department and industry anti-fraud organizations to resolve claims.

Validated medical determination through research including review of regulatory manuals, computer files, and medical documentation.

Adhered to regulatory/statutory guidelines and HIPPA laws.

Ensured the attainment of at least 98% quality scores for all compliance audits.

Reviewed and verified records and activities, to assess their adequacy and effectiveness.

Provided training to new hires regarding process and procedures.

Provided exceptional customer service on inbound and outbound calls.

Reviewed new files to determine status of injury claim and to develop plan of action.

QUALITY AUDITING CLAIMS CONSULTANT 11/2014 – 01/2016

Aetna Phoenix, AZ

Advocate and quality consultant through measuring and monitoring the quality, effectiveness, and detail of work processes in the claims encounter and customer service environment.

Subject matter expert.

Designed and developed new work processes while keeping the current process updated.

Analyzed and resolved complex claim scenarios within established timeframe.

Processed AHCCCS claims and Medicaid claims.

Assessed questionable claims and worked with various agencies and claimants to correct omissions and errors.

SR CLAIMS BENEFITS SPECIALIST/ENCOUNTERS 03/2009 – 11/2014

Aetna Phoenix, AZ

Adjudicated complex, sensitive, and/or specialized claims.

Processed AHCCCS claims and Medicaid claims.

Subject matter expert trainer to fellow benefit specialists in claims encounters.

Collaborated with management to handle customer service inquiries and resolve issues.

Applied medical necessity guidelines and determined coverage.

Completed eligibility verification, identified discrepancies, and applied all cost containment measures to assist in the claim adjudication process.

Worked EDI 837 and EDI 835 files.

Worked with prewritten SQL queries, and Excel.

MEDICAL COLLECTOR 07/2008 – 03/2009

St Luke’s Medical Center Phoenix, AZ

Identified, researched, and resolved billing variances to maintain system accuracy and currency.

Handled phone and written inquiries related to accounts.

Knowledgeable current medical plans including AHCCCS.

Reviewed all adjustments, appeals, payments, and researched denials for all necessary supporting documentation to remit payment.

Verified member's eligibility and updated account insurance information.

Compiled and analyzed data for review by senior management.

Exceeded goals through effective task prioritization and great work ethic.

MEDICAL BILLING LEAD 11/2002 – 06/2008

Capitol Administrators Rancho Cordova, CA.

Maintained contract timelines of claims adjustments and adjudication.

Liaison for 98 districts and all company processing partners.

Participated in required weekly conference calls with the USMS, provided updates and data analysis as needed.

Coordinated and conducted training of all new hires.

Coached/trained new hires on company processes and systems.

Managed and audited over 25 employees daily to achieve maximum production.

Assisted clients with any questions, inquiries, and troubleshooting of elevated issues.

Evaluated workflow processes and implemented modifications to improve overall effectiveness and meet crucial deadlines.

Directed pricing and processing of 300-400 claims daily.

Met contract guidelines for Medicare, Medicaid and CCN.

Produced comprehensive monthly reports for senior management.

MEDICAL BILLING/CLAIMS PROCESSOR 09/2000 – 11/2002

Coram Healthcare Sacramento, CA

Generated new accounts.

Reviewed claims for accuracy and timely submission.

Post and reconcile insurance and patient payments.

Research and resolve incorrect payments, follow-up on rejections and other issues with patient accounts.

Verification of correct ICD-9, HCPCS and CPT codes for a variety of accounts.

Set-up practice management software for submission of electronic claims through clearinghouse.

Retrieve Electronic Remittance Advice ERA’s, send secondary claims upon processing of primary insurance.

Follow-up on insurance and patient aging accounts for resubmission while complying with timely filing requirements.

Ensure compliance with HIPAA regulations.

MEDICAL ASSISTANT 06/1995 – 09/2002

Sutter Medical Foundation Sacramento, CA

Escorted patients to exam rooms.

Performed measurement of vital signs, including weight, blood pressure, pulse, temperature, and documented all information in patient’s chart.

Assisted physician and physician assistant in exam rooms.

Provided instructions to patients as instructed by physician or physician assistant.

Performed chart review and prep prior to appointment including reports, labs and information is available in patients’ medical records.

Managed exam rooms – ensured they were stocked with adequate medical supplies, maintain instruments, and prepare sterilization as required.

Handled telephone messages and called in prescriptions as needed.

Triaged messages to front office staff to physicians and physician assistants.

Maintained all logs and required inspections (i.e. refrigerator temperatures, emergency medications, expired medications, oxygen, cold sterilization fluid change, etc.)

Performed front desk and back-office duties.

EDUCATION

MEDICAL BILLING AND CODING PROGRAM MEDICAL ASSISTANCE PROGRAM

High Tech Institute - Sacramento, CA

Academic Excellence Award

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