Summary
Overview
Work History
Education
Skills
Accomplishments
Timeline
Generic

Aileen B Guihama

Fullerton,CA

Summary

Highly motivated Claims Examiner with robust background in reviewing, analyzing and processing claims. Equipped with strong problem-solving abilities, innate analytical skills and attentive to detail. Successfully resolved simple to complex issues and ensured end-to-end compliance of adjudicating Medical HCFA.

Overview

9
9
years of professional experience

Work History

Claims Examiner

HealthSmart, MSO
07.2019 - Current
  • Participated in team meetings to address organizational challenges related to claims management and develop equitable solution.
  • Analyzed claim data for accuracy, identifying trends to enhance processing efficiency.
  • Reviewed and processed Medical claims with due diligence and adhered to CMS regulatory guidelines.
  • Established strong professional relationship by promptly addressing inquiries and providing accurate information on claim status.
  • Troubleshoot claims that needed additional work in areas of Vendor Set-Up, Eligibility, DOFR and MFS.


Claims Specialist- Senior

HCP / Optum
10.2016 - 07.2019
  • Coordinated efforts with Claims Examiner and Manager of claims Audit findings.
  • Prepared and explained member denial ad hoc analytic reports and was presented to Departmental huddle.
  • Established and built strong professional rapport with HCP's Central Department including Eligibility, Automation, BRU and Utilization Management
  • Conducted regular audits of member denial files, assuring claims were in compliant related to claims adjudication.
  • Provided supporting data analysis from Extract Report of claims processed in error and IS logic challenges.

Education

Certificate of Competency - Network Support Specialist

Southern CA Regional Occupational Center
Torrance, CA
06-2019

Certificate of Completion - Excel 1 & 2

Torrance Adult School
Torrance, CA
12-2018

Certificate of Completion - Medical Insurance Billing Specialist

Southern CA Regional Occupational Center
Torrance, CA
06-2008

Certificate of Completion - Office / Clerical Occupations

Regional Occupational Program
Long Beach, CA
06-2007

Certificate Of Proficiency - Medical Front Office

Southern CA Regional Occupational Center
Torrance, CA
06-2006

Skills

  • Encoder Pro
  • HIPAA / PHI
  • DX Term / Office Ally
  • Microsoft Office / Edge
  • Critical Thinking skills
  • Conducting due diligence
  • Strong communications abilities
  • Team work and collaboration
  • Claims Compliance management
  • Familiarity with IPA structures
  • Experienced in analyzing Vendor contract
  • Expertise in CMS 1500 forms / CPT / DOFR

Accomplishments

  • Used Microsoft Excel to develop tracking billing trends and important notes as a reminder.
  • Kept management posted of area of concerns such as DOFR inaccuracies, Fee Schedule and Provider's Contract and avoided overpayment or underpayment of Medical claims.
  • Combined strategic thinking with well rounded experience and delivered impactful solutions.
  • Valued team player, known for commitment of excellence and supporting Company's objective.


Timeline

Claims Examiner

HealthSmart, MSO
07.2019 - Current

Claims Specialist- Senior

HCP / Optum
10.2016 - 07.2019

Certificate of Competency - Network Support Specialist

Southern CA Regional Occupational Center

Certificate of Completion - Excel 1 & 2

Torrance Adult School

Certificate of Completion - Medical Insurance Billing Specialist

Southern CA Regional Occupational Center

Certificate of Completion - Office / Clerical Occupations

Regional Occupational Program

Certificate Of Proficiency - Medical Front Office

Southern CA Regional Occupational Center

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