Richard Alfaro

Skills

Patient insurance verification, documentation of current coverage, policy guidelines and procedure

review

¢ Use of various computer systems and programs ranging from AS400 to SAP

* Production scheduling and logistics

* OSHA 30 certification and medical compliance certification with TEXAS SPINE and JOINT

HOSPITAL

* Extensive customer service in a front line or escalation call setting

Experience

Centene 11/2018 - Present

Claims Review Specialist

© Process pended medical claims, verifying and updating information on submitted claims and reviewing

work processes to determine reimbursement eligibility.

* Ensure payments and/or denials are made in accordance with company practices and procedures.

* Apply policy and provider contract provisions to determine if claim is payable, if additional information

is needed, or if claim should be denied. Claims processing may be related to physician and hospital

services, coordination of benefits (COB), high doliar, special pricing, refunds and/or adjustments on

resubmitted claims.

* Research and determine status of medical related claims

* Review charges, access the computer system and use payment or denial codes within established

department guidelines and standards

* Clarify health insurance coverage for coordination of benefits to process claims

© Maintain records, files, and documentation as appropriate

‘* Meet department production and quality standards

CREST PROCESS SYSTEMS Tyler, TX 03/2018 — 10/2018

Quality Control Inspector

¢ Inspect piping, fittings, flanges for heat codes; Inspect welds that they meet AWS criteria

® Document and research the heat codes, pull paper work accordingly for review and final QC stamp and

signature

TEXAS SPINE & JOINT HOSPITAL Tyler, TX 06/2016 03/2018

Early AM Admissions Registration/Security

* — Responsible for Early AM patient admissions, registration and customer service

* — Security duties on 2nd and 3rd shifts and weekends when scheduled

¢ — Hospital maintenance duties as needed

FLOWER’S BAKERY Tyler, TX 01/201*-******

Quality Control Inspector

© Inspected processed food product before shipment

* Calibrated machinery for loading product at packaging point

* Trained temporary employees during peak production times

TJC BOOKSTORE Tyler, TX 08/2008 -11/2012

Skipping/Receiving Assistant Supervisor

Receiver and shipper for college textbooks, materials and supplies

© Chief textbook buyback representative

* Academic retail financial aid/intemet sales/customer service

FRESENIUS MEDICAL CARE Tyler, TX 06/2008 -08/2008

Insurance Verification Representative

* Temporary position as an Insurance Verification representative, documentation of patient accounts.

{mostly Oklahoma}

« — Use of the Medicaid and Medicare systems to confirm effective dates and necessary referrals

TRINITY MOTHER FRANCES HOSPITAL Tyler, TX 06/2002 -04/2008

Jusurance Verification Representative

Verified patient insurance through multiple sources

© Precertification of medical procedures per insurance plans and policies

Setting up referrals from primary care givers to Specialists

* Extensive notation of all relevant information on each patient's account and profiles updated

Education

Associate of Applied Science/Process Technology Kilgore College Kilgore, TX

Associate of General Studies/Business Tyler Junior College, Tyler, TX

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