Claims Representative Postal Service
Resume:
Monitra Shine
*** * ******* ** **** Beach, CA 90806
***************@*****.***
Objective
Professional Medical Analyst with over 22+ years of experience helping to empower all departments with high production and meeting deadlines.
Dependable, skilled and experienced with a high degree of integrity and motivation towards the completion of any given task.
Excellent written and verbal communication skills.
Claims experience with QNXT.
Ability to work under general supervision, while prioritizing and organizing daily assignments.
Team player with basic analytical and problem solving skills.
Experience
03/2020 - 08/2022
Core Systems Configuration Specialist II, LA Care Health Plan, Los Angeles, CA
Responsible for daily system configuration inventories and ensured compliance with established service level agreements and timelines.
Audited provider records and affiliations for quality and accuracy and provided documented feedback.
Generated, distributed, and processed configuration reports to facilitate contract affiliations to support claims processing.
Maintained system dictionaries and tables as appropriate.
Troubleshot and participated in defect resolutions of moderate and complex issues related to the assigned configuration component(including the related validation and testing).
Lead related cross-functional process improvement initiatives and activities that support maintaining code sets, etc.
Lead affiliation projects.
07/2008 – 12/2019
Provider Configuration Analyst, Molina Healthcare Inc., Long Beach, CA
Assisted with configuration issues and loaded provider information
Responsible for accurate and timely implementation and maintenance of critical information on claim databases.
Loaded and maintained contracts, benefits or reference table information into the claims payment system.
Analyzed and interpreted data to determine appropriate configuration changes.
Researched and resolved claim/encounter issues, pended claims and updated the system.
03/2007 – 07/2008
Claims Representative, St Joseph Heritage Healthcare, Anaheim, CA
Responsible for consistently and accurately adjudicating all contracted professional capitated claims with fee-for-service carve outs and contracted fee-for- service claims for both Commercial and Senior plans.
08/2003 – 11/2006
Medical Claims Examiner II, Molina Healthcare Inc., Long Beach, CA
Met and consistently maintained production standards for claims adjudication.
Identified and recommended solutions for error issues for pre-payment of claims.
Worked on claims pending reports, including claims aging reports, provider and member research validation.
Coordinated provider and member updates.
Met and exceeded all claims productivity standards and guidelines
12/2000 – 08/2003
Third Party Liability Coordinator, Molina Healthcare Inc., Long Beach, CA
Provided Medical/Billing records to Law Offices, Department of Health Services, and affiliated IPA’s.
Responsible for receiving and responding to subpoenas issued to company for Medical/Billing records.
Handled confidential, financial, and personal matters daily with diplomacy and tact.
Worked closely with other IPA’s to obtain member’s billing information via mail, fax, and US Postal Service.
Served as liaison between doctors and lawyers to obtain confidential patient information.
03/2000 – 12/2000
Encounter Examiner II, Molina Healthcare Inc., Long Beach, CA
Processed 400 Encounter claims per day
Logged and lined claims for Utah, Washington, and California teams.
Researched patient information.
Updated eligibility via the internet.
Education
Educorp Technical College – Long Beach – Billing and Coding Certificate
Contact this candidate