Irma C. Pantoja

Rowlett, Texas *****

Cell 214-***-****

Email: ad4mem@r.postjobfree.com

Summary of Qualifications

Over 20 years of experience in the Healthcare/Medical industry.

10+ years of Health-rule Payor and Claim’s Processing

10+years of Medicare compliance and regulations

Knowledge of ICD-10 codes

Perfect knowledge of Medical Terminology.

Able to identify problems and find solutions, face challenges head on.

Quick and eager to learn; conscientious and detail-oriented.

Knowledge of Hospital and Benefit contract structure and language.

Demonstrated ability to adapt quickly and manage a rapid changing environment.

Professional Background

Dell Services/NTT Data 1/2013 – present

Claims Processing Operations Unit

Medicare Advantasure

Process Training Specialist – 7/21- present

Create and design a Training Program that would successfully train and educate Claim’s Processors on the basic knowledge of claims processing and the IKA system for Medicare Advantasure – Local and ITS.

Coordinate with the client on written instructions for the Desk Level Procedure (DLP) process on seven different Medicare Advantasure clients.

Perform QA Departmental Audits on newly trained Processors.

Implementing changes to our internal Processing Manuals.

Train, coach and develop employees to surpass company objectives and standards

Worked and mentored Unit Leads and provided support to the Supervisor and Manager as needed

Served as the Subject Matter Expert for departments

Claims Processing Operations Unit

Claims Supervisor 10/18 – 7/21

Supervised two units of Claims Processing and Provider Enrollment

Responsible for all departmental Corrective Action Plans (CAP)

Tracked and evaluated individual performance.

Oversaw the day-to-day staffing needs of the department.

Maintain accountability for team performance and proactive with process change.

Oversaw the

Audit and Training –

Lead Quality Assurance Analyst 1/13 – 10/18

Performed pre-pay, post-pay and IKA system audits on Medicare Advantage claims in the IKA System for Local Medicare Advantage and ITS Blue-card claims.

Responsible for Root Cause meeting and assessment of Claim errors and resolution

Researched audit report accuracy and responds to audit appeals to ensure a successful resolution.

Trailblazer Health Enterprises, LLC

CMS Medicare Mac J4 10/2006 – 12/2012

Part A & B Hospital Claims Unit

Claims Unit Lead /Trainer II

Processed, Medicare hospital and professional claims

Responsible for updating Internal and External written work instructions for claim pends and claim processing edits.

Supervised three different team of Claims Examiners to ensure claim production was being met in a timely manner to meet CMS processing requirements.

Attending CMS monthly meetings to discuss an operational plan for Change Requests and Transmittal plan process.

Served as liaison between Claims department and CMS on claim and system issues as well as quality updates done on a quarterly basis.

Assisted management with review and changes with SAS audits and other type of audits that would be sent from CMS.

System tester on new system pends and edits as well as claim changes before going

Blue Cross and Blue Shield of Texas, Inc. 7/1996 – 7/2006

Facility Provider Network Department

Provider Relations Representative Specialist

Created training workshops for Hospital Providers on claim billing guidelines and processing across the state of Texas.

Assisted providers/hospitals in resolving claim and inquiries relating to pricing, coding and Managed Care contract issues – claims billed on UB/1500 claim forms.

Corresponded with the Finance Department on benefit changes, loading rates, and system issues related to how hospital and physician claims are paid and reimbursed.

Created Benefit Plan Contracts in coordination with the Legal Department

Researched legal paperwork for correction of benefits and group benefit plans on HMO, Best Choice, BluCard (ITS) and Manage Care Contracts.

Reviewed all plan documentation utilizing legal information provided for processing and completion of HMO and Manage Care contracts.

Education: Lubbock High School; Lubbock, Texas

Healthcare Management - Richland College

Certificates: Claims Coding Certificate Concorde College; Dallas Texas

Six Sigma Training – White & Yellow Belt

Operating Systems: IKA processing system, Nasco processing system, Blue-Square ITS system, BlueChip, PIPP & PAPP pricing system, Premier pricing system, and CMS FISS processing system

Applications: Microsoft Word, PowerPoint, Microsoft Excel, Novell, Lotus cc: Microsoft Outlook, Microsoft PowerPoint

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