Member Services Los Angeles
Resume:
Martina Mojica
***** ***** ******, *******, ** **220
Objective
Leverage extensive expertise in Taft-Hartley, self-funded and self-administered plans, claims management, and process improvement to enhance daily productivity, resolve escalated issues, and implement efficient systems and benefits programs.
Professional Experience Los Angeles County Fire Fighters Local 1014 El Monte, CA
Senior Employee Benefits Specialist
September 2016 – December 2024
•Conducted audits on medical/dental claims and member services, logging errors for review by management and trustees.
•Led implementation and data configuration of new benefits, auto-adjudication processes, and the member portal.
•Managed escalated issues, appeals, provider refunds, and high-dollar claims approvals.
•Trained new hires and handled software issues, system implementations, and vendor collaboration.
•Proficient in Bridgeway’s basys software platform for claims processing and reporting.
•Regularly prepared reports and presented at industry conferences, earning annual certifications in benefits management.
Claims Manager
February 2006 – September 2016
•Reduced backlog on professional claims (from 15 to 2 days) and hospital claims (from 32 to under 15 days).
•Supervised daily claims processing, enforced policies, and addressed escalated member and provider issues.
•Managed union employee relations, including performance improvement plans and grievance handling.
Interim Claims Manager
September 2005 – December 2005
• Oversaw claims and member services operations during a leadership transition.
Member Services Representative / Senior Claims Processor
July 2005 – February 2006
• Provided benefit quotes, resolved provider/member issues, and processed professional and hospital claims on both basys and Blue Cross (Anthem) systems.
Air-conditioning & Refrigeration Trust Fund Anaheim, CA
Claims Supervisor and Processor
April 2003 – July 2005
•Processed complex medical and dental claims, including refunds, voids, and stop payments.
•Handled contract and provider relations, adding new providers and troubleshooting issues.
•Specialized in Taft-Hartley, self-funded, self-administered plan administration.
•Trained in claims fraud detection and management best practices.
Southern California Pipe Trades Administrative Corp. Los Angeles, CA
Senior Communications Coordinator
1984 – April 2003
•Negotiated contracts with annual savings exceeding $150K.
•Processed claims, authorized benefits, performed audits and resolved member/provider issues.
•Specialized in case management for terminal and trauma patients and managed mental health benefits.
Skills & Expertise
•Claims Management: Auditing, auto-adjudication, appeals handling, backlog reduction.
•Employee Benefits: Taft-Hartley and self-funded plans, implementation of new benefits, training, and compliance.
•Technical Proficiency: Bridgeway - basys software, claims software configuration, reporting, auditing and troubleshooting.
•Leadership: Staff training, union relations, performance management.
•Communication: Presenting at industry events, member service excellence.
Certifications & Training
•Annual Certificates in Benefits (IFEBP, Software Conferences)
•Claims Fraud Training
•Supervisor and Management Training
Interests
Training and mentoring, church leadership, and black belt judoka.
Contact this candidate