Career Profile:

Analytical, Detail oriented Professional, Skilled in resolving problems, Mathematical skills, Learner, Confident professional who facilitates cooperation and communication among parties. Good listener and fast learner to attain organizational goals of our stakeholders in the Healthcare Industry. Knowledge of Centers for Medicare and Medicaid Service (CMS) Compliance Regulations.

Professional Experience:

Molina Healthcare of Puerto Rico

Claims Recovery Specialist San Juan, Puerto Rico 2015 to present

Identify, validate and track overpayments (Benefit Configuration, Payment Policy, NCCI, MUEs, multiple reductions procedures, duplicated claims, Coordination of Benefits, retroactively terminated members etc.) to providers by reviewing claims audits results and provider claims reports.

Handle Provider communication regarding overpayment disputes.

Coordinate analyzing claims overpayments and determine collection recovery strategies.

Prepare written provider overpayment notification and supporting documentation such as explanation of benefits, claims and attachments.

Contact providers and handle collection arrangements for overpayment claimants that have not responded to overpayment requests.

Handle inquires and responses from internal and external callers.

Maintain and reconcile department reports for outstanding payments collected, past-due overpayments, uncollectible claims, and auto-payment recoveries.

Prepare and provide write-off documents that are deemed uncollectible or collections efforts are exhausted for write off approval.

Participate in health plan meetings to review recovery status updates.

Conduct Special Projects as assigned.

Filtered the Recovery Inventory and distributed work to colleagues.

Use of programs such as MS Word, MS Excel, MS Outlook, QNTX Platform (Claim Processing System), Claim Recovery (App to generate letters for possible overpayment and make recoupment)

Clarified doubts from colleagues.

Humana Health Plans of Puerto Rico, Inc.

Specialist, Provider Payment Integrity San Juan, Puerto Rico 2014 to 2015

Responsible of verifying queries to identify overpayments from providers.

Processed recoupment in CAS platform.

Verified audit claims.

Helped with the correction of some query instructions.

Special Investigator Assistant San Juan, Puerto Rico 2013 to 2014

Responsible to make calls to members to verify if services were rendered.

Responsible to make calls to providers to equipment verification (who is the owner of the equipment, who performed the test and their certification).

Requested medical records from providers to verify if they are billing correctly.

Verified claims in the system if they were pertain to the allegation of Fraud, Waste and Abuse.

Processed Claims in Power MHS, CAS and MTV platforms.

Helped in the implementation of Verisk Health for a program that gathers claims that are suspicious of Fraud, Waste and Abuse to be review and determine if the provider should be investigated.

Amended guidelines to be able to Process the claims for Power MHS platform.

Processed Overpayment from providers.

Claims Specialist San Juan, Puerto Rico 2006 to 2013

Analyzed submitted claims by providers to enable us to pay or denied the same.

Prepared Daily Production Report

Used of programs such as Power MHS, MS Word, MS Excel, MS Outlook, NPI Registry Search, Eligibility Finder Plus.

Filtered the Claims Inventory.

Distributed work

Verified Prepayment report to ensure that claims were properly worked.

Provided training to new employees.

Clarified doubts from colleagues.

Referred cases or situations to different departments for the proper action.

Analyzed Grievance and Appeals, Prompt Payment cases and Special Projects submitted by the providers.

Performed validation tests in Power MHS for benefits and configuration montage

Performed tests in the PMHS environment to upgrade versions of PMHS

Shoe Zone

Customer Service Guaynabo, Puerto Rico 2004 to 2006

Responsible for sorting and stocking the store.

Cashier.

Responsible for the sales bank deposit.

Education

B. B. A. Bachelor In Business Administration – Accounting Major

Training:

Yellow Belt Six Sigma, Training Course

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