Summary
Overview
Work History
Education
Skills
Medicalskills
Medicalofficeskills
Timeline
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AMNERIS APONTE-Soto

Deltona,FL

Summary

Versatile Quality Assurance Specialist with extensive experience in interpreting and implementing QA standards, effectively investigating customer complaints and non-conformance issues. Adept in problem-solving and analytical techniques, showcasing proficiency in QA methodologies and tools. Proven track record of enhancing business processes through strategic planning and effective project management, resulting in improved workflow efficiencies. Notable strengths include adaptability, negotiation skills, and exceptional communication capabilities.

Overview

20
20
years of professional experience

Work History

Arbitration Specialist III

US Anesthesia Partners
Orlando, FL
11.2020 - Current
  • Assists the team with gathering data and support for paying decisions
  • Maintains metrics of decisions and filings entered each day
  • Supports the filing of cases and prepares documentation for hearing rotation
  • Ensures that all responses in arbitrations are maintained and filed timely and accurately
  • Handles arbitration correspondence as directed by management
  • Process payment of adverse decisions promptly and address Post Decision Inquiries when applicable
  • Maintains electronic case files and documents to be retained
  • Works with management to maintain annual case budgets
  • I have provided management point of contact support on all assigned cases
  • Completing payments to all Judges /Arbitrators
  • Approving/rejecting extension requests
  • Creating Case folder
  • Update Master tracker with Arbitrator name, Arbitrator Fees, Brief due date, Deadlines/time due, Decision date, and rebuttal submitted to date
  • I must include information from the Arbitrator/Judge for assignment dates, W-9s, and invoices
  • Calculating dates
  • Email inventory
  • Updating Arbitration Suppliers ID and Fees in our Excel spreadsheet updated
  • Updating AP (Accounting Department) Master tracker
  • Making files for TX UHC (Texas United Healthcare), TX CHC (Texas Community Health Choice), CO UHC (Colorado United Healthcare), and any closed files
  • Included but not limited to Ambetter, Federal and State
  • Submitting Suppliers Invoice
  • Assisting all insurance and arbitrators with any request
  • Completing all projects promptly
  • Creating Briefs for both Federal and State
  • Opening open negotiation through the CMS portal
  • Maintaining a 95% -100% accuracy
  • Confirming all offers through Multiplan’s
  • Calling Insurance for NSA open negotiations email and having claims reprocessed for OON (out-of-network)
  • Keeping track of all payments for federal and state
  • Speaking with the Arbitrator and Judge for any issue they have
  • I was looking over any offers that come in
  • Supports all parties, from co-workers to management, as needed, as well as other departments

EDI Team lead manager

Florida Cancer Specialist
Altamonte, FL
06.2018 - 01.2020
  • Supports team manager and performs management duties when the manager is absent or out of the office
  • Encourages team members, including communicating team goals and identifying areas for new training or skill checks
  • Assists management with hiring processes and new team member training
  • Answers team member questions, helps with team member problems and oversees team member work for quality and guideline compliance
  • Communicates deadlines and EDI goals to team members
  • Develops strategies to promote team members' adherence to company regulations and performance goals
  • Conducts team meetings to update members on best practices and continuing expectations
  • Generates and shares comprehensive and detailed reports about team performance, mission-related objectives, and deadlines
  • Ensures company brand materials and physical working spaces meet and exceed company presentation standards
  • Provides quality customer service to all employee's questions
  • EDI reports, batching
  • Insurance knowledge requirements include understanding medical terminology, the managed care authorization process, ICD and CPT codes, and collection experience
  • Created a Welcome Package for new hire

Payment Poster Specialist

Florida Hospital Medical Group
Orlando, FL
01.2016 - 06.2018
  • Ensure accurate and timely payment processing, Read and analyze patient records, and provide continual evaluation of processes and procedures
  • Notify the Billing Supervisor of any variance or potential problems that could delay processing
  • Log all payments received for accounts, write them off to the collection agency, and forward all backups to the agency monthly
  • Identify reports that have yet to be received
  • Maintain a cohesive working relationship with staff and management and work as a team to achieve optimal efficiency and obtain information required to process an order (product references and billing account contacts)
  • Escalate all delays to internal departments where interaction is required
  • This includes communication to resolve questions involving incomplete or inaccurate data on orders and to request additional data as needed
  • Determining the correct codes for patient records, using codes to bill insurance providers
  • Interacting with physicians and assistants to ensure accuracy, Keeping track of patient data over multiple visits
  • Managing detailed, specifically coded information, Maintaining patient confidentiality and information security
  • Insurance guidelines, the claims submission process, and procedures
  • Analyzing Explanation of Benefits (EOB) forms to ensure insurance companies have paid for charges
  • Consult with product teams, trainers, and systems support to identify service-impacting issues
  • Working with attorneys in sending requested updated ledgers
  • Working with claims denials
  • Posting payments from Insurance, cash payments from patients, and third-party payments
  • Reading patient’s records and physician notes

Medical Assistant / Office Assistant

Spine Sports & Pain Medicine
Deltona, FL
01.2010 - 01.2011
  • Administered Scheduling appointments and greeted patients
  • Oversaw completion and submission of insurance forms
  • Reviewed Patient's files/updating/record-keeping
  • Verified Accounts Receivable/Payable
  • Obtained vital signs
  • Performed EKGs, phlebotomy, and lab procedures
  • Allowed maintaining patients' confidential
  • Assisted during physical examinations, Maintaining treatment rooms, Sterilizing instruments
  • They also arrange examining-room instruments and equipment, maintain supplies and equipment, and keep waiting and examining rooms neat and clean

Loan Officer/ Office Assistant

Premier Mortgage Group
Orange City, FL
02.2005 - 06.2008
  • We have developed loan applications by evaluating applicant information and documentation
  • Evaluates loan applications and documentation by confirming creditworthiness
  • Once loans are acceptable for Approval, they forward applications to the loan committee
  • I complete loan contracts by explaining provisions to applicants, obtaining signatures and notarizations, and collecting fees
  • I have helped customers by answering questions and responding to mortgage/credit requests
  • I have Maintained customer confidence by keeping loan information confidential
  • Accomplished bank mission by completing related results as needed
  • Ensure appropriate approvals are in place before order submission
  • Evaluate, authorize, or recommend Approval of real estate
  • Advise borrowers on financial status and methods of payments
  • Including mortgage loan officers and agents, collection analysts, loan servicing officers, and loan underwriters

Education

Certificate of Continuing Education - Electronic Medical Records, 837P and Form CMS-1500, Medical Fraud and Abuse, HIPAA, Infection Control: Environmental Safety, Athena and Collaborate software

01.2021

Bachelor of Science - Healthcare Management

Florida Technical College
Deland, FL
01.2016

Skills

  • Proficient Relationship Building
  • Microsoft Word
  • PowerPoint
  • Excel
  • Proficient in QuickBooks
  • Documentation Management
  • Office Management Skills
  • Communication
  • Time management
  • Cleanliness and organization
  • Following protocols
  • Attention to detail
  • Knowledge of basic medical procedures
  • Computer skills
  • Research skills
  • Interpersonal skills
  • Prioritizing tasks
  • Effective Problem Resolution
  • Team Leadership for 15-35 Members
  • Punctual and Accountable
  • Keeping records
  • Maintaining Focus Under Pressure
  • Maintaining professional and positive relationships
  • Project management
  • Staff training
  • Teamwork
  • Leadership support
  • Cigna portal
  • Allied portal
  • Healthlogic
  • Multiplan
  • Athena IDX
  • Contract Express
  • Workflow automation
  • Team collaboration
  • Business reporting
  • Quality assurance
  • Documentation management
  • Management collaboration
  • Customer relations
  • Knowledge sharing
  • Process optimization
  • Urology coding and billing
  • Medical records
  • Athena
  • Collaborate
  • Intergy software
  • Patient payment
  • Drafting Atty Requests
  • TDI Texas Department of Insurance
  • UHC provider
  • Citrix Receiver
  • Optum ID
  • Medical terminology
  • Billing and coding
  • Collections
  • EHR/EMR

Medicalskills

  • Vital Signs
  • Phlebotomy
  • Injections
  • Specimen Collection
  • Urology coding and billing
  • Medical records
  • Athena
  • Collaborate
  • Intergy software
  • Patient payment
  • Atty request and denial letters
  • TDI Texas Department of Insurance
  • Contract Express
  • UHC provider
  • Citrix Receiver
  • Optum ID
  • Medical terminology
  • Billing and coding
  • Collections
  • EHR/EMR

Medicalofficeskills

  • Great Interpersonal Skills
  • Completed Microsoft Word, PowerPoint, Excel, Quick Books, and Charting/Records Management training
  • Administrative Skills
  • Communication
  • Time management
  • Cleanliness and organization
  • Following protocols
  • Attention to detail
  • Knowledge of basic medical procedures
  • Computer skills
  • Research skills
  • Interpersonal skills
  • Prioritizing tasks
  • Problem-solving
  • Managing a team of 15-35 people
  • Dependable and keeping records and staying focus under pressure
  • High abilities in maintaining professional and positive relationships with patients, medical staff, attorneys, Judges, providers, and all upper management
  • Project management
  • Staff training
  • Teamwork
  • Leadership support
  • Cigna portal
  • Allied portal
  • Healthlogic through Bank of America
  • Multiplan
  • Athena IDX
  • Contract Express

Timeline

Arbitration Specialist III

US Anesthesia Partners
11.2020 - Current

EDI Team lead manager

Florida Cancer Specialist
06.2018 - 01.2020

Payment Poster Specialist

Florida Hospital Medical Group
01.2016 - 06.2018

Medical Assistant / Office Assistant

Spine Sports & Pain Medicine
01.2010 - 01.2011

Loan Officer/ Office Assistant

Premier Mortgage Group
02.2005 - 06.2008

Certificate of Continuing Education - Electronic Medical Records, 837P and Form CMS-1500, Medical Fraud and Abuse, HIPAA, Infection Control: Environmental Safety, Athena and Collaborate software

Bachelor of Science - Healthcare Management

Florida Technical College

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AMNERIS APONTE-Soto