(H) 909-***-**** (E) email@example.com
Summary:Possesses a high degree of Integrity and an outstanding work ethic seeking to apply my knowledge and talents to drive long-term company growth. Skills:
● Organizational skills
● Quality Control
● Building strong relationships
● Thrives under pressure
● Professional phone etiquette
09/2019-11/2019 Care National/CalOptima Health Plan Claims Recovery Specialist
Responsible for performing recoveries on claims that have been overpaid.Reviews and analyzes system generated reports to determine recovery opportunities. Communicates clearly to providers regarding guidelines and the reason for the refund request. Answer provider questions regarding recovery based upon contractual and/or CalOptima agreements, policies and procedures; involving the use of established payment methodologies, initiates and expands recovery opportunities through audits, process enhancements and through system generated reports.
04/2019-07/2019 Judges group/Agilon Health-Corona Ca Claims Research Specialist/Examiner
Adjudicates medical claims according to regulatory and company’s processing guidelines and contractual agreements. Researches, identifies, resolves and responds to inquiries from internal departments regarding outstanding claims-related issues and identifies root causes of claims issues and deficiencies. Follows established policies and procedures and use available resources such as provider contracts, Medicare and or Medicaid guidelines and Member Evidence of Coverage (EOC) to process and adjust routine assigned claims in an accurate and timely manner. Maintains productivity and quality standards as defined by Management. Resolves claims payment issues as presented through Provider Disputes Resolution (PDR) process and or provider calls. Performs payment reviews and adjustments due to retroactive effective date of contracts and or fee schedule changes.
03/2010-03/2018 Beaver Medical Group/Epic Management LP-Redlands CA Claims Examiner
Adjudicates medical claims according to regulatory and company’s processing guidelines and contractual agreements. Processed HMO commercial and senior claims, both professional and facility claims. All claims are processed in accordance with the provider contracts, state, federal, CMS, DMHC, and Health plan guidelines and regulations. Researched all misdirected claims and redirect them to the appropriate place. Researches, identifies, resolves and responds to inquiries from internal departments and providers regarding outstanding claims-related issues and identifies root causes of claims issues and deficiencies. 04/2009-03/2010 Beaver Medical Group-San Bernardino CA Appointment Clerk
Answer phones on multi-line switchboard, set appointments and procedure for patients. Screen calls to see if appointments can be scheduled or if a conference call with their nurse was needed. I had to have the knowledge to learn every doctor’s schedules and how they wanted their appointments booked. Mail out appointment cards with date and time and necessary instruction. We also had to put notes into the system with as much detail as possible.
08/2000-01/2008 ACP/Alliant Insurance-San Bernardino CA Renewal Assistant
Prepared all Renewal for Commercial Policies 90 days prior to Renewal Date. Requesting all information for current year including Loss Runs, DMV reports and any other pertinent information or documentation needed for the Renewal. Set up new files for the current year with all the new updated information. Close out files for prior year and prep them for back-end scanning. Back-up receptionist answered phones, direct clients as they came into the office. Disperse electronic faxes. Sent out overnight packages thru UPS or FEDEX as needed by the staff. Also a back to the mail clerk picked up and delivered inter-office mail, weigh and postage all out-going mail, run folding machine for big mail out jobs as needed, and take all out-going mail to the post-office.
Christy Fimbres-Cell# 951-***-**** firstname.lastname@example.org Pastor at The Way World Outreach/Pastor and friend for 10 years Jessica Pangelinan-Cell# 951-***-**** email@example.com Primerica Insurance agent/Co-worker and friend for 19 years Janet Casas-Cell# 909-***-**** firstname.lastname@example.org Administrator at The Way World Outreach/Pastor, Administrator and Friend for 13 years