Andre Arca

**** **** ***.

Rosemead, CA. *****

Email: adzp5w@r.postjobfree.com

Cell: 626-***-****

Professional Objective:

I am a self-motivated person seeking a challenging career opportunity with an Organization that will allow me to contribute my experiences, knowledge and skills. Desire a position with career growth potential. Thrives in a multi-task environment, solution oriented. I’m a fast-learner, excellent work ethics, hardworking, independent, reliable and an excellent team player and able to grow with the company through versatility and adaptability.

Summary of Qualifications:

Possesses strong analytical and problem solving skills and have experiences in reviewing contract and auditing claims to ensure payment/settlements case are in compliance with State and Federal regulations as well as processing standards established by the Organization. Performs routine and complex audit of claims and identify inaccurate claims adjudication. Summarize findings and recommendations in reports for feedback/correction to the claims examiners and management. Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

Knowledge and Skills:

• Knowledge of all ICD-9, CPT, and HCPC codes.

• Proficient with Federal and State requirements in claims processing.

• Knowledge of general billing for both health care providers and institutions.

• Proficient understanding of AB1455 Claims Settlement Practice & dispute and resolution regulations.

• Generate and utilize reports to perform “pre” and “post” audit for all examiners, at all level and to capture deficiencies in processed claims prior to check run.

• Able to verify that claims are paid in accordance with correct contractual provision regulatory guidelines.

• Able to work independently and successfully with limited supervision.

• Able to work with Claims Examiners, give direction and answer claims related questions to improve overall quality of the department and individual examiners.

• Knowledge of rate application for all outpatient and inpatient facility, ASC, APR-DRG, DRG, interim rate and CMAC rates of payment methods to appropriated line of business. (Medicare, Commercial, Medi-Cal and Healthy Families).

• Identify any incorrect billing, coding, NCCI edits, duplicate payments, and incorrect payment adjudication.

• Proficient in and knows how to use and apply Health Plan Benefit Matrices and Division of Financial Responsibility.

• Proficient in and performs the application of “Coordination of Benefits.”

• Process appeals and/or Provider Dispute Resolution.

• Comply with claims timeliness guidelines: Commercial 45 working days; Medi-Cal 30 calendar days; Medicare non-contracted 30 calendar days and Medicare contracted 60 calendar days.

• Resolve any grievances and complaints received through Customer Service.

• Identify any overpayment underpayment in a review and or history search and Collaborate with Recovery Analyst on any type of overpayment on a claim.

• Recognize claim correspondences from multiple IPAs.

• Recognize the difference between Shared Risk and Full Risk claims.

• Support the Claims Department as business needs require.

• Maintains the strictest confidentiality at all times.

• Complies with all Company and Department Policies and Procedures.

• Attendance at employer worksite is an essential job requirement.

• All other duties as assigned.

Computer Skills Including:

Microsoft Window, Microsoft Office, Microsoft Access, Word, Excel and Power Point

System Experiences:

AS400, NICE, RIMS, EZCAP, FACETS, EPIC

Experiences:

Golden State Medicare Health Plan: August 2019 through Current

PDR Specialist and Claims Appeals and Grievances

Responsible to define the framework, responsibilities, and guiding principles for Golden State Medicare Health Plan (“Golden State” or the “Plan”) for disputed claims

• Provide and maintain a process that addresses the receipt, handling, and disposition of a PDR for NCPs in accordance with applicable statutes, regulations, contractual requirements, and the terms and conditions of this policy.

• Responsible for the Plan’s Claims Department shall accept, track, and report all Non-contracted PDRs.

• Recognize NCPs must file a first level PDR within one hundred and twenty (120) calendar days after the receipt of the notice of initial determination (i.e. EOB’s/RA’s/Letters) the receipt of Remittance for level of payment disputes

• Responsible to provide all parties to a PDR with reasonable opportunity to present evidence or allegations of fact or law related to the issue in dispute in person or in writing. The Plan shall take all evidence into account when making its decision.

• Responsible for process PDRs involving payment disputes about the payment if it is less than the amount that would have been paid under Original Medicare, or payment for a different service than billed, within thirty (30) calendar days after receipt of such appeal.

• Responsible to inform the NCP in the notice of PDR decision of his or her right to file for reconsideration under the CMS provider payment dispute process with an Independent Review Entity (IRE).

• Responsible notify the NCP of the PDR process

• Give examples of decisions Management and Colleagues that typically cannot be appealed to the Plan under the member’s Medicare coverage:

• Cognizant that NCP shall submit the initial payment dispute in writing within the required timeframe and shall include:

• When necessary documentation has not been submitted for review of the Provider Dispute, the payer advises the provider to submit the required documentation.

• Ensure decision on the Dispute must be within thirty (30) calendar days from the date the Payment Dispute is first received by the payer, and

• Ensure Interest must be paid on such claims in the same manner as provided for all other claims. If the original claim was underpaid in error, then interest would be required on the additional amount of the payment due, from the date of the original claim until the date the claim was reprocessed. Interest would be calculated in the same manner as interest on all claims, which is discussed in the Medicare Claims Processing Manual

• Advice NCP may file with the IRE if the NCP is not satisfied with the decision issued by the Plan, or a decision is not issued within the thirty (30) calendar day time limit.

• Notify Non-Contracted Provider Reconsideration Request

Imagenet LLC: April 2016 through July 2019

Senior Claims Auditor

Responsible for ensuring the compliance of Medicaid and Medicare claims payment system and processes by auditing claims payments using standard principles and State and Federal regulations. Also responsible for the research and recovery of claims overpayments/underpayments including COB and Third Party Liability

• Audit internal systems and controls to ensure the claims system is set up correctly and claims are processed in accordance with contractual and regulatory requirement per internal guidelines

• Prepare reports on audit results, identify trends and implement quality improvement activities for improving business process

• Initiate and expand recovery opportunities through audits, Provider calls, Third Party Liability and CCS Eligible services

• Audit payment errors that result in Provider refund checks to determine the root cause and Provide the Claims Dept with a detailed description of the reason for the refund and how to apply the refund in claims processing system

• Ensure all payment fee schedules, procedure code files and requlatory bulletins are appropriately implemented and maintained timely

• Communicate with and answer Provider inquiries and/or Provider disputes regarding the reason refund request based upon claims processing guidelines, contractual agreements involving the use of established payment methodologies and regulatory guidelines

• Perform other duties as required to ensure the Health Plan operations are successful

• Ensure the privacy and security of PHI as outlines in the Medicaid/Medicare’s Policies and Procedures relating to HIPAA compliance

• Promote teamwork and maintain effective working relationships with others throughout the Organization

Synermed: November 2014 through 2016

Claims Auditor

Responsible for ensuring the compliance of Medi-Cal and Medicare claims payment system and processes by auditing claims payments using standard principles and State and Federal regulations.

• Performs audit and adjudication of high dollar claims while maintaining acceptable levels of claims inventory and age of claims

• Ensures claims payment accuracy by first verifying patient’s eligibility, pre-authorization, system pricing and medical necessity of claims

• Initiate and expand recovery opportunities through audits

• Completes and maintains detailed documentation of audit which includes pricing methodology, system or processing errors and dollar amount discrepancies which are used for financial reporting and trending analysis

• Provides feedback to both Manager and Staff on claims processing errors and identifies quality improvement opportunities

Caremore Health Plan: August 2001 through 2014

Claims Auditor

Responsible for performing pre and post payment audit and review payment accuracy of claim for Medicare, Medi-Cal and Commercial lines of business

• Performs audit and adjudication of high dollar claims (Case rate, Stop Loss and Settlement case) while maintaining acceptable level of claims inventory and age of claims

• Ensures claims payment accuracy by first verifying patient’s eligibility, pre-authorization, system pricing and medical necessity of claims

• Initiate and expand recovery opportunities through audits

• Completes and maintains detailed documentation of audit which includes pricing methodology, system or processing errors and dollar amount discrepancies which are used for financial reporting and trending analysis

• Provides feedback to both Manager and Staff on claims processing errors and identifies quality improvement opportunities

Huntington Provider Group: October 1994 through 2001

Claims Examiner III

Responsible for proper adjudication of claims in accordance with claims Policy and Procedure and Internal guidelines

• Determine level of reimbursement based on established criteria, Provider’s contract or Health Plan’s provision

• Identify and report adjudication inaccuracies that are related to system configuration, benefit inconsistency and fee schedules

• Identify circumstance that require claim payment, development or denial of claims

• Review and research Provider inquiries and payment dispute, including re-adjudication of claims if necessary

Education:

Covina High School

1989 – 1993

HS Diploma

Mount San Antonio College

Summer 1993

Pre-requisite

Reference available upon request

Contact this candidate