Lead Project Specialist Claims Department

Edward Ayala Lead Project Specialist – Claims Dept.

*********@*****.*** www.linkedin.com/in/edwardayala91324 805-***-**** Northridge, CA 91324

Detail-oriented and results-focused Claims Analyst with expertise in Managed Care. Highly analytical professional able to closely review data, identify variances, and initiate corrections. Engaging communicator skilled in handling all aspects of Managed Care claims projects and processing.

Areas of Expertise include:

Claims Analysis / Auditing

Workers’ Compensation

Liability / Coverages

Written / Oral Communications

Policy / Procedural Implementation

Third-Party Liability / COB

Insurance / Terms

Litigation / Actionable Plans

Contract Negotiations

Professional Experience

REGAL MEDICAL GROUP / LAKESIDE COMMUNITY HEALTHCARE Northridge, CA 2014 - Current

Lead Project Specialist – Claims Dept.

I lead a team dedicated to streamline the claims processes by conducting thorough analysis and research, implementing regulations in provider contracts, and awarding appropriate payments. Heavily participate in the negotiation process for new provider contracts based on previously paid claims. Enforce compliance and facilitate open lines of communication to promote consistency.

Additional Key Contributions:

Oversee the preparation and transfer of project reports for Symkey automation; expertly navigate internal software.

Exemplify a dedication to integrity-based practices and accuracy while adjusting claim payment disputes.

REGAL MEDICAL GROUP / LAKESIDE COMMUNITY HEALTHCARE Northridge, CA 2010 - 2014

Senior Claims Examiner

Repeatedly exceeded expectations of quality by managing multiple complex projects simultaneously and excelling within strict deadlines. Adhered to all policies and procedures while reviewing provider contracts and interpreting terms and conditions. Strengthened team performances by offering comprehensive training to new staff members.

Additional Key Contributions:

Displayed meticulous detail when ciphering through all customer documentation to make fair judgements.

Reduced wait times for resolutions by liaising among all parties and keeping communication clear and concise.

REGAL MEDICAL GROUP Northridge, CA 2008 - 2009

Claim Examiner III

Outpaced established goals and upheld high-volume production by reviewing 250 claims daily. Exemplified expert time management skills and organizational qualities by distributing time appropriately based on complexity of claims. Protected client privacy by handling sensitive information with discretion. Called upon avid research and analysis skills to supervise claims across multiple lines of business and provide accurate information to claimants.

Additional Key Contributions:

Achieved an accuracy level of 98.5% by double checking work, verifying information, and utilizing industry acumen.

Worked cohesively with third parties and cross-functions to reach determinations and distribute rulings.

Additional experience as a Claim Examiner at Medical Professionals Staffing (1 year), a Senior Revenue Recovery Analyst at Cap Management Systems/Tenet Healthcare (5 years)

Training & Qualifications

Coursework: HMO claims administration for Commercial, Senior, Medi-Cal and Exchange members

Technology: SYMKEY Automation, EX-Cap claims administration software, Microsoft Office Suite

Contact this candidate