Sr. Claims Examiner

OBJECTIVES:

Seeking a challenging position in the Healthcare Industry where my knowledge, skills and lifetime experience can be utilized to the fullest.

Scan Health Plan August 2017 to March 2023

Sr. Claim Examiner

Process Complex UB04- MAPD/ MMP Medicare Inpatient, Home Health, Skilled Nursing and ESRD claims with 100% accuracy by applying SOP.

Follow HIPPA, CMS guidelines, company policies and procedures

Comply and exceed department’s production and quality standards

Process each claim accordingly with Medicare contract Rates and sometimes use DOFR.

Webstrat priced High Dollar Claims

Replacement claims reprocess accordingly.

HCFA Claims village claims Transplant claims.

Molina Healthcare February 2015 to August 2017

Sr. Claim Examiner

Process Complex UB04- MAPD/ MMP Medicare Inpatient, Home Health, Skilled Nursing and ESRD claims with 100% accuracy by applying SOP.

Follow HIPPA, CMS guidelines, company policies and procedures

Comply and exceed department’s production and quality standards

Process each claim accordingly with Medicare contract Rates and sometimes use DOFR.

So. California UFCW April 2004 to January 2015

Claims Adjuster

Review and process various types of medical claims in accordance to plans’ guidelines and provisions.

Reviewed Anthem’s WGS and Citrix systems to verify documents and claim status

Adjusted claims as directed

Complied and exceeded department’s production and quality standards.

Handled all assigned duties in a timely manner

ATI STAFFING SOLUTIONS

COAST HEALTH PLAN Sep 2013 to March 2014

Claims Examiner

Determined covered medical insurance losses by studying provisions of policies

Established proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims

Documented medical claims actions by completing forms, reports, logs, and records

Resolved medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter

Ensured legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations

Maintained quality customer services by following customer service practices; responding to customer inquiries

Assembled documentation for counsel in preparation for settlement

Complied with departments confidentiality policies

Collected data to analyze and prepare detailed reports

Received many accolades for accomplishing urgent assignments

SCAN HEALTH PLAN Jan 2009 to May 2013

Claims Examiner

Processed Medicare, HMO, PPO Contracted Provider and Non-Contracted, secondary payer claims following all established government guidelines and procedures for payment

Maintained 95% accuracy meeting daily production standards

Follow HIPPA, CMS guidelines, company policies and procedures

Troubleshoot and resolved claims issues that have been pending on various edits

Reviewed and reconciled daily batches from the finance department

Analyze patient/clients outstanding accounts receivable, refunds and process requests for adjustment

Maintained compliancy for governmental regulations, audit claims to make sure AHCCCS claim edits reimbursement amount are correct per contracts. Reviewed benefit payments and followed with providers on outstanding balance accounts.

Verified bulk payments were applied to correct patient accounts.

Complied with turnaround time policies.

SCAN HEALTH PLAN Dec 2007 to May 2008

Member Services Representative

Processed member and /or provider information, answering member questions; verified member eligibility for providers

Functioned efficiently and productively in a high volume telephone call center

Maintained department productivity standards

Provided follow-up assistance as needed

Sent claim status correspondence to providers and members

Universal Care Feb 2005 to Aug 2007

Claims Processor

Processed claims for the IPA

Identified dual coverage, potential third party liability cases and reinsurance case

Requested additional information for possible recovery

Maintained current working knowledge of products, policies and procedures

Assisted Appeal Unit with Disputes

Processed contracted provider, non-contracted provider, HMOs, PPOs, DME and EMR claims

Processed senior claims complying with 30 days turnaround time

Followed HIPPA CMS compliance guidelines

Performed job related duties as assigned by management or department heads

Education:

Socorro High School El Paso, TX

San Joaquin Valley College Bakersfield, CA

Skills and Abilities

Excellent time management skills

Effective verbal and written communication skills

Fluent in Spanish, written, spoken, and translation

Team player and can work well independently

Familiar with general claims review and appeal process

Strong understanding of HIPPA/CMS guidelines and compliance

Detailed and highly organized

Excellent research skills

Analyze A/P reports for claims recovery

Experienced in Word, Excel, and PowerPoint

Familiar with systems: MC400, IDX, PMMIS, MDE-Pen Analyzer, Snagit, TI Portal, MC Net, EZ-CAP, EZ LINK, BOWMAN, Anthem WGS, and Content Framework.

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