Astrana Health

- Performs through review of pended claims for billing errors and or questionable billing practices that might included duplicate billing and unbundling of services.
- Process non institutional claim types for all line of business (Medicare, Medical, Commercial)
- The specialist should clearly understand the products and healthcare benefits services offered to customers, including cost share, limits and regulatory rules and guidelines.
- Configure  provider contracts. Fee schedule updates and other documents.
- Develop configuration testing & validate accuracy of data loaded.
- Communicated required system updates to provider contracting & claims operations.
- Coordinate research & resolution of debarred & sunctioned providers 
- Corrects system generated errors manually prior to final claims adjudication.
- Process claims based upon the providers contract/agreements or pricing agreements,applicable regulatory legislation, claims processing guidelines and NMM policies and procedures 
- Analyzes and validates Medi-cal pricing researches, Adjust and adjudicates claims reviews services for accurate charges and utilizes current billing codes,sets (international Classification Disease (ICD 10) codes. Current Procedural Terminology (CPT) codes and/or authorization guidelines as reference.
- Validates eligibility and other possible health insurance coverage on the claims (Medicare  primary, California Children services (CCS).
- Alerts manager or supervisor or more complex issues that rise.
- Process claim exception reports as assigned.
- Other duties as assigned by management
- Recognize claim correspondences from multiple IPA’s.
- Recognize the different between Shared Risk and Full Risk claims
- Maintain required levels of production and quality standards as established by management.
- Attendance at employee worksite is an essential job requirement 
- Work assigned claim project to completion 
- Contribute to team effort by accomplishing related results as needed.

Claims Examiner III

Altais- Health System FKA Brown & Toland PSO

Conduct investigations to discover the reason for unpaid or underpaid claims or reimbursements, verify records and documentation, and ensure that all required paperwork and supporting materials have been submitted properly including escalation or collection procedures, if necessary. Responsible for researching claims overpayments, recoveries, and related appeals on all types of claims, working with internal and external stakeholders to facilitate claims recoup payment. Interpret contracts and benefits, correct claims coding and billing. Responsible for maintaining and tracking all incoming refunds and processing claims as Offset.

Claims Recovery Analyst

Brown & Toland Physicians

Settle claims through the evaluation of facts of a customer's situation surrounding their claim. Responsible for determining whether the loss is covered and what compensation should be. Investigate thoroughly to ensure that an insurance claim is not fraudulent and may be required to contact relevant third-parties including a doctor, an employer, or to consult with a police report. Negotiate insurance settlements, authorize payments, and keep records. Interpret medical policy as it relates to claim payment at the direction of the Claims Supervisor or Claims Manager. Understands and interprets medical policy established by the Brown & Toland Medical Group. Maintain departmental productivity goal. Maintain departmental productivity goal. Maintain a 97% payment accuracy rate and 98% non-payment accuracy rate in Claims Services.

Claims Representative I, II

Aux Delices Restaurant

Greeting Customers. Take orders and deliver items as requested. Ensure customers satisfaction.

Waitress

Office Depot

Help Customer Service, Operating the cash register. Void a credit card or cash transaction, and to return a credit card, return of merchandise. Stocking, arranging the merchandise. Handling of phone calls and greeting of customers, any questions.

Cashier

Group Health Cooperative - HMO

Process medical records. Maintenance of clinic charting system. Including the preparation of client folders. Coordinate of form for information, coding. Answering phone, mail & Filing

Health Information Technician I

Herrero Brothers, Inc General Contractor

Payroll as Account Receivable, Account Payable. Assisting Administrative Judges with filing, typing, and organizing files. Answering phone, mail, time sheet, Invoice Document

Accounting Clerk

State Historical Society of Madison

Data Entry Using Excel, Word Perfect, and Paradox.  Assemble packets of information requested and prepare envelopes. Mailing, photocopy documents.  Speed Type, Microfilm.  Answering phone

Clerical Assistant I

Department of Revenue State Record-Madison

Tax Clerk

Madison Area Technical College-Madison

Tutor Assistant (Math as Algebra).  Computer – Lotus 123, dBase, WordPerfect, Excel, Etc

Assistant Tutor

To obtain a position whereby my skills and professional experience can contribute to the company.

Purpose: Under direct supervision, reviews and adjudicates paper/electronic claims, as Commercial, Medicare, Medi-Cal. Determines proper handling and adjudication of claims following organizational policies and procedures and also Epic System and EZ-CAP System 

Apollomed:
NMM - Network Medical Management
IHPC - Imperial Health Plan CA
BNDS - Brand New Day Medicare
CTACCFY - Central Health Plan Medicare Access FYB
BDACCFY - Brand New Day Medicare  Access FYB
APCMG - Access Primary Care Medical Group
CN - Pending New Credentials 
AAMG - All American Medical Group

Healthplan Code/Name (AAMG)
CALS - Anthem Blue Cross Medicare
BDAAMFY - Brand New Day Medicare AAMG FYB
HNES - Health Net Medicare
BDNS - Brand New Day Medicare
BS- Blue Shield Commercial 
SFHM - TPA San Francisco Health Plan 
Medi-Cal
CALM - Anthem Blue Cross Medi-Cal




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