Carlos C. Rivera

*** *. ****** ***, #*

San Diego, CA 92103.

619-***-****

aduzo4@r.postjobfree.com

Summary of Qualifications:

Highly experienced insurance Claims Processor with over 17 years of progressive experience in business administration, sales and customer service

Fast, accurate and efficient data entry expertise, knowledge of medical terminology from UB/HCFA claims, procedure coding, ICD9 coding and fee schedules

Consistently met 99% accuracy performance requirements with 9,000 keystrokes per hour. Experience manually pricing claims using on-line pricing contracts. Resolved multiple exceptions based on definitions of exception codes. Verified high dollar claims pricing.

Computer Skills: MS Windows and Macintosh operating systems, Word, Word Perfect, Excel, Power Point, Eudora, Netscape, Form Ware, Meeting Maker, People Soft, Epic, Bright Tree, All Script

Ability to learn new customized systems quickly and report generation and project allocation experience

Works well independently and as part of a team

Recognized as positive and professional with initiative for productivity, responsibility and bottom line profitability

Professional Experience:

Sharp Medical Records Department Kearny Mesa, CA 08/22-12/22

Health Information Technologist (Clinical Hours for course completion)

Opened daily incoming mail, separating payment checks and medical records requests

Date stamped medical records requests

Looked up patient data on All Scripts software

Approved or denied requests via HIPPA rules and guidelines in a timely manner

UCSD La Jolla, CA 09/20-02/21

Call Center Specialist

Register new and returning patients, along with scheduling appointments and verifying insurance coverages.

Answering a multiple phone-line system.

Completing online registration.

Securing authorization for appointments.

Faxing

Filing

Assist medical staff with projects

Solomon Page Staffing San Diego, CA 08/19-03/20

Medical Claims/Biller

Processed Ambulance claims from various providers ranging from Medi-Cal, Medicare, HMO’s, PPO’s, and Commercial claims in a timely manner using Epic and Bright Tree software.

Contacted providers and patients to verify eligibility, process payments, follow up on unpaid past due accounts, provide financial assistance programs or payment plans.

Investigated & Corrected claims that were on pending or denial status. Processed Trauma hospital claims analyzed & corrected incorrect procedure codes & modifiers. Input patients, ER & surgeon medical notes into a DMS database for management to review for monthly history tracking report.

ATI Staffing San Diego, CA 05/13-07/19

Medical Claims Data Entry/Examiner

Processed incoming HICFA and UB claims on a timely and accurate manner meeting daily quota status: 250-350 claims per day.

Researched contracts to resolve claims that were denied for procedural code error or various other reasons.

Denied claims due to incorrect information processed on medical claims by the billing provider or approve claims due to system error on our behalf.

Providence Health Plans Portland, OR 10/08-11/2011

Operations Support Specialist

Handled incoming intake phone calls from members regarding coverage options, benefits information, co-pays, and various plan inquiries

Processed all incoming claims and ensured complete accuracy: Approximately 250-270

Claims per day

Consistently met and exceeded claims quotas

Ensured accurate ICD-9 and CPT codes were used for each claim

Worked exclusively with HMO,PPO and Medicare insurance plans

Received Financial Accuracy Award for 12/08/2009

Cigna Health Insurance Phoenix, AZ 12/05-09/08

Medical Claims Processor

Processed and entered medical claims into company-wide system; handled approximately 300 claims per day

Worked directly with large hospitals within the Phoenix area

Interacted with patients directly and provided excellent customer service to all members

Completed Fed Ex medical claims course- 02/2006

Received Financial Accuracy Award for 03/2006-08/2006

Received Perfect Attendance Award for 2006

First Health/Pacific Care Scottsdale, AZ 08/03-12/05

Medical Claims Processor

Handled the review and submission of hospital medical claims; worked directly with the claims Department of various hospitals in Scottsdale area

Processed an average of 300 claims per day with extreme attention to detail and accuracy

Took incoming intake phone calls from members regarding benefits and eligibility information

Received Perfect Attendance Award- 08/2003

Safeway Inc., Phoenix, AZ 02/01-08/03

Customer Service Representative

Processed human resource requests, including payroll discrepancy reconciliations

Handled all previous employment verification for new hires

Acted as trainer for new employees with People Soft program

Interacted with customers directly and always upheld customer service standards

Express Personnel San Diego, CA 03/97-01/01

Administration Assistant/Data Entry Processor

Managed five copy centers

Input payroll records for all 5 locations

Accountable for pricing, obtaining orders, organizing meetings, and processing worker’s compensation claims

Internal Revenue Service Long Island, NY 08/87-02/97

Data Entry Clerk

Performed accurate and fast data entry on IRS tax records

Recognized with 1993 Manager’s Award and 1992 Five-Year Service Award

Received a cash bonus award 1991 for accuracy in the review and recording of incoming tax forms including 1040’s and 895’s

Education:

San Diego Community College San Diego, CA 09/20-12/22

Health Information Technology Associates Degree

Pacific College of Oriental Medicine San Diego, CA 09/12-Present

Massage Therapist Certificate

Portland Community College Portland, OR 09/10-06/12

Attended medical-pre-requisites courses

Healing Arts Connection Phoenix, AZ 08/08

Reiki Master/Teacher & Chair Shiatsu Massage Therapist

(NCBTMB)National Certification Board of Therapeutic Massage and Bodywork

Tucson Art Center Tucson, AZ 06/97

Associates in Advertising Art

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