Mirella Valdovinos

**** * ********* ******, *******, IL 60645 • 773-***-**** • ad4313@r.postjobfree.com

PROFESSIONAL SUMMARY:

Self-motivated professional with over 25 years of technical experience in the healthcare industry. A problem solver with the ability to view problems in a positive way and propose solutions to improve work strategies. Handles multiple tasks simultaneously, meet deadlines, work well under pressure, and adapt to change well. Knowledgeable of reimbursement methodologies for Illinois Health Care and Family Services (HFS) and Centers for Medicare and Medicaid Services (CMS).

HIGHLIGHTS:

Organizational, analytical, and decision-making skills.

In-depth knowledge of ICD-9, ICD-10 and CPT coding.

Reimbursement Methodology for Commercial, Medicare and Medicaid programs; HMO, PPO, Medicare Advantage, ICP, and MMAI/MMP.

Administrative skills in a business office setting have developed my abilities to multitask and organize in clerical duties while providing excellent customer service.

Tools include but not limited to: Microsoft Office suite, Excel, Outlook, EZ Caps, Beacon, Basys, Quick Cap, Encoder Micro Denn.

Bilingual in Spanish both oral and written communication.

PROFESSIONAL EXPERIENCE:

SEIU LOCAL 1 06/2018- 03/2024

Claims Adjuster

Processing health, disability, and UHS manual claims according to the Plan of Benefits.

Responding to general telephone inquiries regarding benefits and claims.

Assisting client walk-ins.

Review and balance weekly registers (Disability).

Report FICA amounts to auditor (Disability).

Voiding and reissuance of disability checks.

Sorting checks for the purpose of mailing out members.

Clerical duties when claims clerk is absent.

Special projects as needed.

FAMILY HEALTH NETWORK 03/2016 - 05/2018

Claims Analyst

Received and responded to all escalated provider issues and ensured standards were established, met, and maintained.

Assisted in the resolution of claims payment and provider systems set-up issues.

Managed and processed medical claims for Medicaid and MMAI.

Maintained and exceeded all productivity goals, quality standards and aging timeframes.

Identified claims with inaccurate data and forwarded to appropriate department for second level review.

CHICAGOLAND MEDICAL SERVICES 12/2014 - 02/2016

Claims Specialist

Investigated, resolved rejected/denied claims and resubmitted claims for further consideration.

Reviewed and analyzed detailed claim form to ensure proper adjudication.

Assisted Supervisor and Team Leader with examining duplicate, timely filing, and explanation of benefits report.

Calculated reimbursement and copays according to contract and most current ICD 9-10/CPT Code.

Compared data on claim form with patient information in Quick Cap System.

Examined claim form in Quick Cap system to determine eligibility and insurance coverage.

Ensured HCFA/UB claims were adjudicated based on the most recent ICD 9-10/CPT codes for the date of service.

ACE COMBINED INSURANCE CO. 08/1985 - 10/2014

Claims Adjuster

Provided comprehensive administrative support to staff handling accident, health, worksite, and life insurance claims.

Accurately processed claims under Supplemental Accident & Worksite coverage.

Determined eligibility by evaluating claim submission and comparing to policy benefits.

Requested additional information from policyholders, providers, and others as necessary to finalize claim.

Created claim related correspondence and managed pended files.

Conducted telephone assessments for continuing disability claims.

EDUCATION:

Catherine College Chicago, IL – Executive Secretary

1986

Senn High School Chicago IL – High Diploma

1985

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