Training Medical

Silvia M. Cuesta

**** ** **** *** #** Miami, FL 331**-***-*** 0504 *******@*****.***

Objective Seeking a managerial position with a progressive organization where in I can use my varied

administrative skills in a company that is rich in diversity and potential for growth.

Profile _________________________________________________________________________________

Self motivated, personable Claims professional with a wide diversity of experience. Over 20 Years of Medical

experience. Have been involved in numerous areas of the trade such as Training development, Healthcare

administration, assisting and testing of internal implementation and development of policies and procedures.

.Flexible and versatile – able to maintain a sense of direction under pressure. Poised and competent with

demonstrated ability to easily learn new medical skills. Thrive in deadline driven environments. Excellent team

building skills.

Skills Summary _________________________________________________________________________

1. Training/ Development of Documentation 7. Testing/Implementing

2. APC Guidelines 8. Kowledge of UB04

3. DRG 9. INFOMAP

4. ICD 9 /ICD 10 10. Professional Coder

5. HIPAA REGULATION 11. Medical Terminology

6. SIX SIGMA/LEAN Yellow Belt 12. Excel 2010

13. Microsoft Access

_______________________________________________________________________________________

Employment History ____________________________________________________________________

AVMED HEALTHPLANS – MIAMI, FL

QI SPECIALIST/ JULY 2012 TO PRESENT

• Responsible for maininting quality and HEDIS reporting to accreditation. Researching, identify and

implementation of interventions to improve Hedis metrics.

• Implement quality management strategies and programs. Create programs and policies to reduce cost

and improve the productivity of the organization through the organization and maintain

documentation of quality initiatives.

TEAMHEALTH – SUNRISE, FL

SYSTEMS ANALYST/TRAINING MANAGER, MARCH 2011 TO MAY 2012

• Responsible for supervising Trainers and maintaining the accuracy of the companies audits. Also,

responsible for approving and reviewing the department’s budget in terms of training.

• Supervised auditors in order to maintain their high dollar accuracy for Facility claims as well as

Professional claims.

• Responsible for gathering business requirements, designing, developing, implementing, testing and

maintaining several projects in order to facilitate doctors census documentation and maintenance.

• Prepare project plans for small projects and system implementation such as the IMED system while in

turn educating the Providers and their Hospital Coordinators on their functions and duties. Also,

resolving Provider issues and conducting meetings regarding their concerns.

Silvia M. Cuesta

ADP/ AUTOMATIC DATA PROCESSING – Miami, FL

LICENSED HEALTH INSURANCE AGENT/ OCTOBER 2010 TO MARCH 2011.

Sold and serviced Health, Life, Disability and Worker’s Compensation products to small business as well as

individual policy.

EMBLEM HEALTH/ HIPA/ HIP HEALTH PLANS – Miami, FL

Senior Claims Trainer/ Business Analyst July 2003 to October 2010.

Responsible for all training within the organization for Florida as well as New York, Texas and

•

Connecticut

• Identified and created training documentation that can be used throught the organization to ensure

that all materials are in concert with Company policies and Procedures along side with Platform and

presentation skills.

• Performed and documented root-cause analysis in order to determine underlying reasons for claim

suspensions

• Presents recommendations and specification in formal reports and presentations

• Support the implementation and ongoing operational maintenance of the life cycle of a claim.

Organized user test cases, training material and training schedules

• Participated in the development, deployment and ongoing maintenance of new technologies

• Develop/modified workflow and procedures based on new policies, new business opportunities or

new legislation using Microsoft Visio or similar workflow management applications

• Worked in conjunction with BTS and MIS/IT in matters relating to Medical & Hospital system logic.

Maintained logic modification listing to correct or improve claims processing. Identifies the need for

new messages to improve understanding of Explanation of Benefits

• Assumes a Leadership role in the development, review, issuance, and modification of claim policies

& procedures for distribution via Sharepoint

Reason For Leaving: Would like to further my career by pursuing a more challenging opportunity.

CLAIMS Auditor: October 2002 to July 2003

Identify inconsistencies and trends in High Dollar claims and bring them to the attention of the appropriate

management personnel

Identifying and tracking error trends made by examiners/personnel by making recommendations for improvement.

Claims Examiner II: December 1998 to October 2002:

Responsible for adjudicating approximately 300 claims per day

Knowledge of Managed care payer compliance .

Made recommendations to management in order to increase productions.

Education: Bachelor’s Degree in Psychology

University of Miami – June 1989

4724 SW 67th Ave #E3 Miami, FL 331**-***-*** 0504 *******@*****.***

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