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Manager Health

Cerritos, CA, 90703
October 23, 2019

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***** ******* *** 562-***-****

Cerritos, CA 90703 *

Provider Systems Configuration – DOFR/Benefits Manager – -

PDR Claims Auditor -Claims Manager

Seasoned, highly knowledgeable Provider Systems Configurator and Claims Manager with over 30 years of experience in the healthcare industry, with a proven track record of generating significant improvements for various businesses, eager to share expertise with fellow employees to optimize company potential. Specializes in creating and troubleshooting various types of Divisions of Financial Responsibility, establishing benefit options and fee schedules for all kinds of businesses and identifying and resolving any and all provider issues. Able to design calculators for ASC and OPPS/APC to ensure correctness of fee schedules. Proactive with the development of quick processing instructions for any outstanding issues.

Currently seeking administrative position in Claims, DOFR, Benefits and/or Compliance.

Areas of Expertise

OPPS/ASC Payment Rates

Provider Dispute Resolution(s)

Employee Supervision

Health Plan Benefit Options

Division of Financial Responsibility

Maximum Out of Pocket Benefits

Provider Fee Schedules

EZCAP Systems

Instruction Manual Writing

Key Skills Assessment

Medicare/Medi-Cal – Strong background in Medicare and Medi-Cal regulations as well as provider disputes, appeals and grievances, audits and recovery, as well as system reviews for member benefit loading and assigning fee schedules such as MPFS, DRG, APC, ASC, DME/P&O, Ambulance, CMAC, Rogers Amendment and others.

Expense Reduction – Significantly reduced company expense from unnecessary financial exposures from incorrect load of benefits between professional versus hospital services, as well as resolving incorrect provider fee schedules, processing errors due to misinterpretation of contracts, policies and reimbursement guidelines.

Training Materials and Supervision – Adept at developing training materials and programs regarding auditing and compliance for new hires and existing staff. Able to implement these materials into training programs while providing consistent supervision and mentorship for all staff during and after training.


Discovered and resolved overpayment situations in excess of $234K, $877K an $1M

Network Support Claims Manager while at Citizens Choice, creating benefit options and assigning provider fee schedules

Manually developed services for all benefit options for each health plan, including Care First, Health Net, LA Care, etc.

Able to map and track benefit options for different years in EZCAP and Ehealth systems

Assigned fee set schedules for various providers in both professional and hospital settings

Trained and managed staff of 40 in problem-solving methods for claim areas

Improved procedures for gathering information on reporting data for continued support of staff and personnel

Coordinated encounter submissions for each IPA

Professional Experience


System Configuration Analyst

Setting up provider adds based on Act Forms received from Provider Outreach Department

Set up appropriate fee schedules for provider adds based on lines of businesses

Update provider address and remittance / vendor address or with new tax ID (TIN#) numbers

Assists Claims Departments on claims reviews before check runs through Billed Charges reports

Adding missing CPT/HCPCS codes missing in the system

Setting up correct fee schedules based on contracts

Configure system for providers not set up in xpress system

COAST HEALTHCARE MGMT, LLC, Cypress, CA Sep 2015 – MAR 2019

Claims Provider Dispute Resolution (PDR) Auditor

Responsible for 10 IPAs

Monitor and Audit Provider disputes to ensure compliance with AB1455.

Track and trend Medicare Provider Disputes to ensure timely handling based on CMS guidelines.

Prepare all correspondence regarding disputes in compliance with regulatory regulations and Coast policies.

Assist with resolution of incoming calls.

Communicate with Providers and Members when required.

Perform other assigned duties / special projects on an as-needed basis.

Respond promptly to any complaints in accordance with policy in employee handbook.

ACCOUNTABLE IPA, Signal Hill, CA Sep 2014 – May 2015

Provider Systems Configuration/DOFR Benefits Manager/ EDI Lead

Responsible for EDI encounters and tracking of member Eligibility.

Support 2 EDI Examiners on process of electronic files with the vendor.

Resolved EDI issues with providers providing feedback to IT department.

Performed troubleshooting of incorrect loads of DOFRs and benefit options for various Medicare, commercial and Medi-Cal health plans for businesses, including Anthem Blue Cross, Health Net, Care First and Citizens Choice.

Improvised the development of fee schedules missing from Ehealth system, to include OPPS/ASC payment rates.

Collaborated with Claims department auditors on all daily audits.

Designed specific processing instructions for issues with provider call handling.

MSO/IPA Claims Manager (Jun 2014 – Sep 2014)

Effectively resolved provider issues by conducting thorough customer service calls.

Developed specific processing instructions for individual services such as Clinical Lab with Modifier 26, ESRD coding and payment rates, Emergency/Non-Emergency Coding and others.

Brought any and all provider issues to swift and efficient resolution, serving such providers as Unitecd Therapy Network, Acaria Pharmacy, internist/pulmonologist/hospitalist providers and many more.

Consistently updated personal understanding of Medicare and Medi-Cal fee schedules.

Trained newly hired remote examiners to have a comprehensive understating of all internal business rules.

Key contributor to the auto-adjudication of certain health plan services.

HEALTH SOURCE MSO, INC., Alhambra, CA Nov 2013 – May 2014

Claims Manager

Designed benefit master and detail options in both EZCAP and Ehealth systems for all lines of business.

Resolved the incorrect setup of DOFRs.

Oversaw 6 employees in a call center for MSO and self-insured customers, as well as 14 examiners and 4 auditors.

Brought any claims processing issues to swift resolution.

Monitored all fast track inventories for provider dispute resolution, regular claims and provider calls.

CITIZENS CHOICE HEALTH PLAN, Cerritos, CA Feb 2012 – Nov 2013

Network Support Service Manager

Served as EDI coordinator and performed all associated duties.

Mapped, tracked and updated provider fee schedules and the yearly member benefit package.

Escalated unresolved detail errors by conducting fax blasts to IPAs.

Updated CPTs and HCPCS codes and carried out crystal reports for overpayments.

CENTRAL HEALTH INC., Diamond Bar, CA Nov 2009 – Feb 2012

Quality Control Training Specialist/Recovery Coordinator

Trained employees for CMS Pricer on DRG, LTCH, OPPS and other codes.

Audited cap-deducted claims and disputed unwarranted cap deductions for health plan.

Composed crystal reports of overpayments identified through referrals from claims and other departments.

Oversaw all follow-ups on overpayment refund letters.

Claims Manager (Oct 2007 – Nov 2009)

Served as Compliance Officer for Central Health.

Conducted monthly timeliness reports for each health plan.

Managed claims staff of 22, from mailroom to supervisor.

Provided training and guidance for staff on any updated guidelines regarding claims processing and payment for Medicare, Medi-Cal and other lines of business.

ARCADIAN MANAGEMENT SYSTEMS, San Dimas, CA Apr 2006 – Oct 2007

Claims Auditor

Conducted accounts payable reports for both “urgent” and “regular” check runs.

Reviewed and audited health plan’s Medicare line of business for professional and hospital providers.

Composed and distributed overpayment letters for refunds.


Fullerton/Garden Grove, CA

Medicare Training Instructor (Contract)

Trained retired administrative law judges, lawyers and paralegals in 2 sessions: Executive Overview in Medicare Coding and Reimbursement Process, and Demystifying Coding and Reimbursement Process.

GREATER NEWPORT PHYSICIANS (GNP) IPA, Newport Beach, CA Jul 2005 – Mar 2008

IPA Specialist Claims Trainer

Served as Advisory Board Member for American Career College.

Served as code review analyst for unbundling of services.

Wrote and designed a basic claims training manual, and created various new policies and procedures.

Trained new and existing employees on claims processing and consistently updated them on CMS guidelines.

ADVANCED MEDICAL MANAGEMENT (AMM), INC., Long Beach, CA Aug 2003 – Jun 2005

Claims Analyst

Leader of Genesis IPA for provider dispute resolution.

Served as stop loss adjustor for Good Samaritan Hospital and Santa Teresita Hospital.

Coordinated senior and health plan demand letters for these hospitals.

UNIVERSAL CARE, Long Beach, CA May 2000 – Jul 2003

Stop Loss Adjustor Level III

Served as stop loss claim processor with billed charges from $25K to $99K.

Processed all Cal-Optima claims on a daily basis.

Senior Healthcare Advantage Claims Coordinator (2000)

Composed senior denial letters to providers and members when existing CSC letters were not implemented.

Confirmed complete adherence to Medicare guidelines by auditing specific policies and procedures.

Implemented fee guidelines for ambulance blended rates.

Audited employees’ paperless pended claims and provided feedback on any errors.

Claims Trainer (2002)

Trained California and Tennessee employees in claims processing and provided claims training to other department employees such as the director, manager, auditor and others.

Claims Auditor Coordinator (2003)

Developed and launched entire audit department.

Trained new auditors on auditing process, as well as recovering monies.

Updated claims to financial, facilitating their quick mailing to providers.

Achieved a Health Net compliance audit of 100% for Universal Care, which was previously not compliant.

Education & Certifications

BS, Social Work

Silliman University, Dumaguete City, Philippines (1978)

Teaching Credentials

California State University Long Beach, Long Beach, CA (2006)

Silliman University High School

Dumaguete City, Philippines (1974)

Government, Regulatory Affairs and Compliance, (Universal Care), February 2001

Advisory Board Member, American Career College, November 2005

WordPerfect 5.1, (Whittier Adult School), December 1994

Webpage Design, (ABC School), February 2005

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