Adriana Medina
Houston,TX
Summary
Dynamic Medical Claims Processor with proven expertise at HMAS, adept at resolving complex claims issues and ensuring compliance with HIPAA regulations. Recognized for enhancing claims processing efficiency through meticulous attention to detail and exceptional customer service, resulting in a significant reduction in denied claims. Proficient in ICD-10 coding and committed to continuous learning.
Professional with experience in healthcare administration, specializing in processing and managing medical claims. Skilled in data analysis, claim adjudication, and ensuring compliance with industry regulations. Strong focus on teamwork and achieving results through effective communication and adaptability to changing needs. Reliable and efficient in handling high volumes of claims while maintaining accuracy and confidentiality.
Diligent Desired Position with comprehensive background in processing medical claims. Proficient in accurately reviewing and adjudicating claims, ensuring compliance with policies and regulations. Demonstrated ability to resolve discrepancies and collaborate effectively with team members to achieve optimal results.
Experienced with medical claims processing, including thorough review and adjudication of claims. Utilizes strong analytical skills to identify discrepancies and ensure compliance with regulations. Track record of effective collaboration with team members and efficient problem resolution.
Medical professional with extensive experience in processing medical claims, including claim review, adjudication, and resolution. Known for strong focus on collaboration and achieving results, adapting seamlessly to changing needs. Possesses key skills such as attention to detail, excellent communication, and problem-solving abilities.
Overview
9
9
years of professional experience
Work History
Medical Claims Processor
HMAS
03.2023 - Current
- Processed high volumes of medical claims accurately and efficiently under tight deadlines, ensuring prompt payment for services rendered.
- Researched and resolved complex medical claims issues to support timely processing.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Verified patient insurance coverage and benefits for medical claims.
- Managed large volume of medical claims on daily basis.
- Monitored and updated claims status in claims processing system.
- Paid or denied medical claims based upon established claims processing criteria.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Assessed medical claims for compliance with regulations and corrected discrepancies.
- Reviewed provider coding information to report services and verify correctness.
- Reduced errors in claims submissions through meticulous attention to detail and thorough review processes.
- Responded to correspondence from insurance companies.
- Collaborated with healthcare providers to ensure accurate billing information was submitted, resulting in fewer denied or delayed payments.
- Maintained a thorough understanding of the intricacies involved in processing medical claims for diverse healthcare specialties, enabling accurate and efficient claim adjudication.
- Identified and resolved discrepancies between patient information and claims data.
- Ensured compliance with all applicable regulations by maintaining strict adherence to HIPAA guidelines and company protocols when handling sensitive patient information.
- Streamlined communication between departments by developing efficient methods for sharing claim status updates and relevant documentation.
- Contributed to positive team morale through active participation in department meetings, offering constructive feedback, and supporting colleagues when needed.
- Processed insurance payments and maintained accurate documentation of payments.
- Maintained a high level of customer satisfaction by promptly addressing inquiries and resolving issues related to medical claims.
- Assisted in the development of training materials for new hires, improving overall team knowledge and productivity.
- Resolved discrepancies between billed amounts and allowed charges promptly by working closely with both providers and payers, minimizing delays in payment processing times.
- Generated reports on medical claims processing activities and results.
- Utilized analytical skills to identify patterns and trends in claim submissions, leading to the development of targeted strategies for reducing errors and improving overall department performance.
- Provided exceptional support during audits by supplying detailed records of claim transactions as needed, ensuring full transparency into department operations.
- Identified opportunities for process improvements within the claims department, leading to increased overall efficiency and reduced costs associated with claim reworkings.
- Stayed current on industry trends and changes in insurance policies, enabling accurate interpretation of coverage details for various plans.
- Mastered various proprietary claim processing systems quickly allowing seamless adaptation to new technology initiatives within the organization.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Managed a portfolio of complex cases requiring extensive research, coordination with multiple parties, and diligent follow-ups to secure reimbursement for clients.
- Coordinated with other departments to ensure seamless integration of new policies and procedures, minimizing disruption to ongoing operations.
- Reduced turnaround time on claim payments by proactively identifying potential roadblocks and addressing them preemptively.
- Followed up on denied claims to verify timely patient payment and resolution.
- Increased claim processing efficiency by implementing new software and streamlining workflows.
- Handled escalated claims-related issues professionally, working diligently towards resolution while maintaining strong relationships with both clients and providers alike.
- Verified client information by analyzing existing evidence on file.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Checked documentation for accuracy and validity on updated systems.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
- Maintained confidentiality of patient finances, records, and health statuses.
- Prepared insurance claim forms or related documents and reviewed for completeness.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
- Coordinated with contracting department to resolve payer issues.
- Generated, posted and attached information to claim files.
- Posted payments to accounts and maintained records.
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
Agent
Amtex Auto Insurance
09.2016 - 03.2023
- Informed clients of policies and procedures.
- Maintained accurate records of client communications, transactions, policies, and other relevant documentation for seamless operations within the agency.
- De-escalated and resolved customer complaints with punctual, polite and professional service.
- Delivered exceptional customer service by proactively addressing concerns and fostering a positive experience throughout all interactions.
Education
High School Diploma -
Davis High School
Houston, TX06.2006
Skills
- Critical Decision-making
- ICD-10-cM coding
- Customer service
- Claim denial resolution
- HIPAA compliance awareness
- Medical record review
- Organizational growth
- Claims processing proficiency
- Insurance claims processing
- Quality assurance checks
- Thorough claims reviews
- Professionalism and ethics
- Continuous learning mindset
- Medical Terminology Familiarity
- Insurance verification
- HIPAA
- Medical terminology
- Fraud detection skills
- Medical coding expertise
- Knowledgeable in software
- Telephone etiquette
- Proficiency in software
- Provider relations
- Scrupulous records management
- Inpatient records coding
- Insurance claims
- Financial analysis
- Data security procedures
- Healthcare billing
- CPT code mastery
- Claim validity determination
- ASC coding
- Electronic claims processing
- ICD codes
- Fee billing
- Electronic health records (EHR)
- Insurance claims management
- Lapsed case follow up
Languages
Spanish
Native or Bilingual
Timeline
Medical Claims Processor
HMAS
03.2023 - Current
Agent
Amtex Auto Insurance
09.2016 - 03.2023
High School Diploma -
Davis High School
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