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Claims Examiner Encoder

Litchfield Park, AZ
July 25, 2021

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Lupe Estrada



Education: Skills:

High School Diploma- Parkridge Private School Type 60 wpm Windows Long Beach CA Ten key DOS A400 QMACS

Commercial Academy- Mexico Proficient in Medical Terminology IDX Systems EZCAP Health Line Systems

Knowledge of ICD-9, ICD-9 & CPT codes

Employment Experience:

2/2019 – 7/2021 Advanced Medical Management, Long Beach Ca Job title: Sr Claims Examiner

Adjudicate claims in accordance polices and procedures base on Terminology Knowledge of ICD-9, & CPT codes on Provider’s Contract/Agreement or pricing rate application for outpatient Inpatient Facility DRG, APC ESRD Rehab CMS Pharmacy AWP processed complex Sr Medicare Commercial ERISA Stop Loss & High Dollar Claims, verify pricing conform prior authorizations assist in resolving escalate issue.

4/2018 - 2/2019 Da vita Healthcare El Segundo, Ca

Job title: Sr Claims Specialty

Processed High Dollar & Complex claims for all types of facility UB’s - HCFA Medical, Medicare Senior Advantage Plans & Commercial, review appropriate payments audits for payment, denial payor review eligibility, authorization contracting and/or provider set up review and evaluate incoming claims for appropriate coding against charges that are billed, determine level of reimbursement based on it knowledge of and ability to process all Medicare claims types including, but not limited to professional services, ambulance transportations DME’s inpatient facility DRG/ APC for outpatient, ESRD pricing. 7/14 – 1/15/2018 Syner-Med-Monterrey Park, CA

Job title: Claims Examiner III

Processed UB’s-HCFA Medical-Medicare Senior Claims, responsible for the accurate review, input and adjudication of provider contracts, adjudicate multiple surgical procedures and anesthesia claims. Knowledge of concepts of capitation, fee-of service using health plan matrices, process high dollar professional, facility, DME Ambulance APR DRG/APC pricing, Dialysis Home Health Care, Skilled Nursing using AWP pricing for Pharmacy Drugs, Interpret Contracts, Medicare-Medical Fee schedule rates.

01/09-7/2014 Monarch Medical Group-Irvine, CA

Job title: Senior Claims Examiner

Examine and process all claims HCFA, UB's, Commercial, Cal-Optima, Medi-Cal, Senior, Contract, Non-contract in a timely manner. Review and research for authorization status. Verify member eligibility. Check DOFR for group vs. health plan responsibility. Review and interpret contracts, letters of agreement, and case rates. Verify copays, coinsurance, deductibles, and resolve COBs. Review and respond to all written appeals correspondence. Process complex chemotherapy, dialysis, and home health claims using AWP pricing for pharmacy/drugs, interpret contracts, Medicare fee schedules and Medi-Cal rate audit all claims in question, identifying billing errors and incorrect payments, if overpayment has been made report to recovery department. Identify system pricing inconsistencies and report to information systems to update. Adjust all Medi-Cal claims processed in error. Deny all appeals ineligible for adjustments and submit proper correspondence to providers and health plans. Working knowledge of ICD-9, HCPC, and CPT-4 codes, ASA Medicare fee schedule, and Medi-Cal fee schedule, Encoder Pro. 8/08-12/2008 Prospect Medical Group- Santa Ana, CA Job Title: Senior Claims Examiner III

Review, research, and analyze professional and hospital institutional claims for 52 health plans. Makes benefit determinations and calculations of payment based on established criteria and provider contracts and resolve claims issues. Identify authorizations and match authorization to claim. 3/07-06/2008 Western Medical Management – Irvine, CA Job Title: Senior Claims Examiner and Customer Service Responsible for Cal OPTIMA/Medi-Cal, Healthy Families Commercial, Senior and hospital claims. Adjudication of complex high dollar facility claims. Processing of claim resubmission request for underpayment. Responsible for appeals and grievances submitted by providers in accordance with AB1455 regulations. Customer Service responsible for verification of provider contracts, authorizations, information and member eligibility.

Additional Work History and References upon Request

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