Ana Montes
Claims/Appeals Specialist
The Woodlands,TX
Summary
Appeal Specialist specializing in denial management and payer policy navigation. Proven track record in analyzing complex claims and crafting persuasive appeal letters, resulting in successful issue resolution. Proficient in EHR systems and remote tools, maintaining compliance and productivity in virtual healthcare environments. Strong negotiation, conflict resolution, and regulatory compliance skills improve labor relations and employee management outcomes.
Overview
17
17
years of professional experience
Work History
Claim Specialist
ACRETIS REVENUE GROUP
05.2025 - Current
- Investigate insurance claims to determine their validity, coverage, and liability, ensuring compliance with policies and regulations.
- Collecting medical records, police reports, bills, and other relevant documents from providers, insurance companies, and patients to assess the extent of injuries and damages.
- Document specific claims by completing and recording forms, reports, logs, and records.
- Provide legal support by assembling documentation for settlement action.
- Maintains a good relationship with insurance departments.
Appeals Manager
MEDREVIEW
10.2024 - 02.2025
- Oversaw workflow among employees to ensure maximum productivity and quality standards were met.
- Prioritized work to ensure completion of designated area responsibilities and functions to ensure claims were completed promptly per the client’s SLA (service level agreement).
- Interfaced with Appeals Leadership regarding operational issues affecting the processing of claims.
- Reviewed and monitored all monthly QA reports and recorded the team’s productivity and error rates.
- Worked collaboratively with the management team to develop a plan of action for employees with high error rates and low productivity.
- Worked closely with the Director of Appeal Operations to ensure the ongoing implementation of new policies and procedures related to the QA process.
Appeals and Grievance Coordinator
EVOLENT
10.2021 - 10.2024
- Received and processed appeals and grievances following organizational policies and procedures.
- Analyzed newly received cases to ensure they were routed and classified correctly.
- Investigated and efficiently and effectively resolved assigned member grievances within the required timeframe.
- Ensured thorough, accurate, and timely processing of provider reconsiderations and member appeals for the plan's internal clinical review and prepared the necessary documentation for all external Medicaid Fair Hearing processes.
- Provided recommendations and identified improvement opportunities to reduce the risk of non-compliance with appeals and grievance requirements.
- Maintained a log of all complaints, grievances, and appeals inventory assigned to the Appeals and Grievance team.
Legal Assistant
THE TUREK LAW FIRM, PC
The Woodlands
08.2017 - 10.2021
- Worked as a High-dollar inventory appeals and denials specialist.
- Contacted and drafted legal appeal letters for various insurance groups to dispute/overturn hospital/physician’s claim denials.
- Researched insurance plan denial reasons against all regulatory rules governing the plan to confirm whether the insurance followed proper claim administrative procedures.
- Worked with different insurance plan types, including but not limited to commercial and government plans, including Medicaid, Medicare, Veterans Affairs, and workers' compensation.
- Worked on all appeal levels, including preparing cases to be reviewed by CMS IRO & IRE.
- Prepared mediation and trial binders for Fair Hearings and Federal Hearing proceedings.
Appeals and Denials Manager
ALEGIS REVENUE GROUP (formerly Meridian Revenue Solutions)
The Woodlands
05.2011 - 07.2016
- Led and developed full-scale project plans and executions.
- Defined the project scope of work, financial plan goals, and delivery.
- Identified resources required, assigned responsibilities, and coordinated project staff directly and indirectly to ensure the successful completion of the projects.
- Responsible for establishing, meeting, and exceeding operational workflow and productivity to meet the company’s collections goals.
- Tracked and resolved critical issues to minimize project risk factors.
- Developed policies and procedures for processing Insurance Denials and Rejections based on coding issues.
- Communicated extensively with clients, subcontractors, and vendors to establish cordial/effective working relationships.
- Responsible for designing, developing, and deploying monthly reports used as a QA tool by Alegis and clients.
- The Appeals and Denials performance and trend report reviewed specific categories of the revenue cycle, including, but not limited to, productivity, compliance, accuracy, effectiveness, and efficiency of the work completed by each department.
- Responsible for reconciling reports between the client’s inventory and Alegis’ inventory.
Appeals and Denials Supervisor
MERIDIAN REVENUE SOLUTIONS
The Woodlands
01.2009 - 05.2011
- Interviewed and hired seasoned and temporary staff for the Appeals and Denials department.
- Provided ongoing training to the Appeals and Denials Coordinators to ensure understanding and compliance with HIPAA and collection rules and regulations.
- Tracked deadlines to ensure accurate and timely completion of assigned inventory.
Education
Certificate of Technical Studies - Business Management Specialization
Lonestar College
The Woodlands, TX05-2017
High School Diploma -
Fermin Toro High School
Maracaibo05-1992
Skills
- Denial management and appeals
- Payer policy interpretation
- Epic systems and Cerner
- Availity and Meditech
- Microsoft 365 and Office Suite
- Data validation and Excel
- SharePoint collaboration
- Project management strategies
- SSRS reporting and analytics
- CPT, ICD-10, and HCPCS coding
- HIPAA and CMS compliance
- Written communication skills
- Patient advocacy initiatives
- Remote collaboration techniques
- Time management practices
- Workflow optimization strategies
- Bilingual Spanish-English
Languages
Spanish
Native/ Bilingual
References
References available upon request.
Timeline
Claim Specialist
ACRETIS REVENUE GROUP
05.2025 - Current
Appeals Manager
MEDREVIEW
10.2024 - 02.2025
Appeals and Grievance Coordinator
EVOLENT
10.2021 - 10.2024
Legal Assistant
THE TUREK LAW FIRM, PC
08.2017 - 10.2021
Appeals and Denials Manager
ALEGIS REVENUE GROUP (formerly Meridian Revenue Solutions)
05.2011 - 07.2016
Appeals and Denials Supervisor
MERIDIAN REVENUE SOLUTIONS
01.2009 - 05.2011
Certificate of Technical Studies - Business Management Specialization
Lonestar College
High School Diploma -
Fermin Toro High School