SUMMARY:

• A professional with more than thirteen years of health care experience who is eager and willing to learn new skills and meet new challenges for career growth and opportunities.

CORE COMPETENCIES:

• Electronic Medical Record experience
• Medicare, Medi - Cal, IPA/Managed Care
• QNXT system proficient
• Proficient with PC based systems
• Typing 50 wpm
• 10k-key by touch
• Excellent Customer Service Skills
• Strong analytical and communication skills
• Ability to take direction and work with minimal supervision
• Ability to demonstrate mature judgment, initiative and critical thinking
• CPT & ICD10 knowledge

PROFESSIONAL EXPERIENCE:

Confidential, Los Angeles, CA

Systems Configuration

Responsibilities:

• Understand health plan’s environment and how QNXT software can be used to increase efficiencies and cost effectiveness.
• Conducted and facilitated meetings to develop and coordinate the requirements, specifications, design, and testing efforts for assigned projects
• Assist in planning and coordination of application upgrades and releases
• Prepared high level user documentation and training materials
• Worked with internal and external stakeholders to understand business objectives and processes associated with the Medicare and Medi-Cal lines of business
• Project Lead for Configuration and Corporate initiatives
• Development of Configuration Standards and best practices
• Conducted gap analysis to identify root cause and assisted with problem management
• Developed and executed test strategies, plans, scenarios, and tracked resolutions to identify defects
• Managed defect reduction via being pro-active in identifying error issues, trends and communicating the issue/improvement idea to management on a weekly basis or within scope of work.
• Supported supervisors/manager with time sensitive reports, special processes, etc.
• Defined and developed test plan documentation to support system validation and/or User Acceptance Testing
• Managed multiple tasks and projects simultaneously to successful completion
• Adhered to and met all deadlines

Confidential, Long Beach, CA

Claims Adjuster

• In depth research and adjudication of underpaid and/or denied claims
• Adjudicate or re-adjudicate claims in a timely manner to ensure compliance
• Handled special projects as assigned and required by changes in claims payment policies or contracting methodologies
• Managed defect reduction via being pro-active in identifying error issues, trends and communicating the issue/improvement idea to management on a weekly basis or within scope of work.
• Handled complex claims such as stop loss, per diem, percentages of claims contract billed
• Supported supervisors/manager with time sensitive reports, special processes, etc
• Consistently maintained quality standards
• Exceeded production goals on a consistent basis
• Routinely reviewed state specific guidelines to ensure correct claims processing
• Managed multiple tasks and projects simultaneously to successful completion
• Processed rebuttals in accordance within the established turn-around-times
• Adhered to and met all deadlines

Confidential

Medical Claims Examiner

• Processed UB-04 claim forms
• Handled complex claims such as stop loss, per diem, percentages of claims contract billed
• Assist coworkers with claims issues
• Responsible for running the POA report and process findings on a daily basis
• Consistently met deadlines on time sensitive projects

Confidential, Lakewood, CA

Medical Claims Examiner

• Processed CMS 1500 claim forms
• Examine pended claims on the EZ Cap system to determine correct payment
• Meet with IPA director for claims trend analysis
• Maintained claims log system for 6 IPAs
• Consistently met deadlines on time sensitive projects

Confidential, Los Angeles, CA

Medical Claims Examiner

• Process imaged CMS 1500 claim forms
• Examined pended claims on the MHC (Managed Health Care) system to determine correct payment of benefits or denial based on applicable fee schedule and/or pricing,
• Pended claims for First Heath and Blue Cross pricing
• Adjudicated professional, ambulance, child claims to determine correct payment of benefits or denial based on the contract benefit guidelines
• Processed claim adjustments in a timely manner
• Adjudicated institutional claims (UB04) within a 10 day turnaround span
• Met goals on assigned special projects
• Consistently exceeded production goals

Confidential

Patient Services Representative

• Provide a consistently high level of service to our patients and providers with a strong commitment to the St Joseph, values, vision and mission
• Satisfy the patient and provider needs in a friendly manner
• Assist providers with inquiries regarding claim payments, denials, EOB interpretation, and appeals process
• Taking inquiries from multiple healthcare insurance providers to satisfy their fiscal reports and requests in a professional manner

Confidential, Bell, CA

Front Desk Clerk

• Greet customers and resolve customer inquiries
• Facilitate the needs of wine importers to manage in house stock alongside with administrative duties
• Process incoming orders, review documents for accuracy and complete follow-up revisions
• Coordinate transportation to schedule appointments for delivery on a daily basis to maintain 100% shipping efficiency

Confidential, Los Angeles, CA

Medical Claims Examiner

• Examined suspended claims to determine payment or denial based on Centers for Medicare & Medicaid regulations
• Consistently meet and exceed production goals of processing 250 claims per hour
• Consistently meet and exceed quality goals of 97% accuracy
• Perform monthly quality reviews of fellow examiners
• Assist supervisor on special projects