HERMILYN M. IBARRA
Long Beach,USA
Overview
30
30
years of professional experience
Work History
Health Smart MSO
Cypress, CA
09.2019 - 03.2026
- Duties: Responsibilities including processing medical claims inpatient/outpatient DME, drugs and medical supplies. Answering phone customer service for providers checking claims status.
Advance Medical Management (AMM)
Long Beach, California
09.2016 - 09.2019
- Duties: Responsibilities includes processing claims in area of San Diego County following health plan Molina Medi-cal, Molina Senior Carefirst Senior Healthnet Senior, Aetna Medi-cal Brand New Day Senior and Commercial claim and Centene (Formerly Health Net) Medi-cal claims in the Queue and status 2 & 3. Lag report for Senior and Medi-cal Contracted and Non Contracted Provider. Working with standard and crystal report after finished processing claims. Processing claims using DOFR. Calling provider to request whatever information needed to pay the claim. Helping other IPA like SMG (Seoul Medical Group) and AMG (Access Medical Group) if they need help to process claims. Senior Plan if no authorization on file we need to call the provider to request medical record or ask for their fax number so we can fax the request letter for medical record. Or do the unclean claim.
MEDICAL PROFESSIONAL
Long Beach, California
03.2016 - 08.2016
- Duties: Responsibilities includes processing Molina Medi-cal, Senior and Commercial claim and Centene (Formerly Health Net) Medi-cal claim in the Queue and status 2 & 3. Lag report for Senior and Medi-cal Contracted and Non Contracted Provider. Working with standard and crystal report after finished processing claims. Processing claim using DOFR. Calling provider to request whatever information needed to pay the claim. Helping other IPA like SMG (Seoul Medical Group) and AMG (Access Medical Group) if they need help to process claims.
ACCOUNTABLE HEALTH PLAN IPA
Signal Hills, California
04.2006 - 03.2016
- Duties: Responsibilities include processing and approving,suspending, denying medical claims included Medicare patient or Senior plan. Matching Trial EOB and claims, answering phone, To ensure timely payment balance of the billed amount. Communicating with providers and patients explaining reason for claims denial and/or to gather additional information in order to process claims approval and payment. Processing claims using matrix to determine if patient is under their contract so that we know whether to deny and/or bill Health Plan. Matching checks and eob and mailed out to provider. Updating provider information to the system especially if provider have a new tax id number need to update. Working with Special Project and PDR (appeal)
CLAIMS EXAMINER
UNIVERSAL CARE
Signal Hills, California
03.2003 - 04.2006
- Duties: Responsibilities include processing and approving,suspending, denying and auditing medical claims before release payment to the provider. Updating co-insurance (medi-cal, medicare and other commercial insurance payment if the EOB attached to the claim). To ensure timely payment balance of the billed amount. Responsible for training newly hired examiner to ensure that processing claims are conducted prescribed by policy and procedure. Processing claims using matrix ( list of medical group or IPA with contract with universal care) to determine if patient is under their contract so that we know whether to deny and/or bill IPA. Select correct provider and read interprets provider contract. Processing claims of state of California and Tennessee. Adjudicate (pay/deny) minimum 1000 claims per week
CLAIMS EXAMINER
UFCW
Cypress, California
02.2005 - 12.2005
- Duties: Responsibilities include processing and approving claim, pending and denying medical claims before release payment to the provider. Reviewing Chiropractic/Acupuncture claim if diagnosis code with 8,9 and E code need to generate a letter if its accident or not. Retiree claim need to update bucket for office visit, surgery, physical therapy, laboratory and radiology. Non par provider need to check blue cross pricing or allowed amount and manual adjudicate and update bucket. With other insurance EOB need to check also blue cross pricing or allowed amount multiply whatever percentage of the plan (A,B,C and Retiree) and update whatever other insurance payment and bucket also.
CLAIMS EXAMINER
WESTERN GROWERS
Irvine, California
03.2004 - 12.2004
- Duties: Responsibilities include processing and approving claims, pending and denying medical claim before release payment for provider. Reviewing claims if this is pre-existing need to generate a letter after 30 days if sending letter if there is no responds denied it. Accident claim need to generate a lein letter so we can know what kind of accident (car, at work or home). Select correct provider and read and interprets provider contract. Adjudicate minimum 1000 claims per week.
CLAIMS EXAMINER
UNIVERSAL CARE
Long Beach, California
01.2002 - 12.2003
- Duties: Responsibilities include processing and approving,suspending, denying and auditing medical claims before release payment to the provider. Updating co-insurance (medi-cal, medicare and other commercial insurance payment if the EOB attached to the claim). To ensure timely payment balance of the billed amount. Communicating with providers and explaining reason for claims denial and/or to gather additional information in order to process claims approval and payment Responsible for training newly hired examiner to ensure that processing claims are conducted prescribed by policy and procedure. Processing claims using matrix ( list of medical group or IPA with contract with universal care) to determine if patient is under their contract so that we know whether to deny and/or bill IPA. Select correct provider and read interprets provider contract. Processing claims of state of California and Tennessee. Adjudicate (pay/deny) minimum 1000 claims per week
BILLER
PER'SE TECHNOLOGIES
Cypress, California
12.1995 - 12.2001
- Duties: Responsibilities include analyzing and resolving interface problems (error and go live report), updating patient, doctor and insurance information and records. Working with halley report (electronic coding), inputting charges (pathology, radiology and emergency). Monitoring information PPO, HMO, MEDI-CAL AND MEDICARE insuring proper procedures and codes are adhered to prior to disbursements for payment. Also responsible for gathering patient information by direct calling patient, hospital and doctor’s office to ensure all information is accurate. Calling insurance company for the eligibility of the patient.
Education
Certification - Electronic Data
Manila, Philippines01-1985
B.A. Degree - Business Education
Polytechnic University of the Philippines
Manila, Philippines01-1983
High School Diploma - undefined
Southeastern College in the Philippines
Manila, Philippines01-1979
Skills
- Extensive Experience in multi-tasking with high degree of efficiency and success
- Extensive experience in Medical Billing and Insurance policies ( PPO, HMO CALOPTIMA, MEDI-CAL AND MEDICARE)
- Extensive experience in records management, reports auditing and preparatory work for upper management staff
- Excellent communications (written & verbal) organizational and conflict resolution
- Proficient in the use of Microsoft office and graphic and desktop publishing application Ten key (by touch) at 12,000 keystrokes and typing (45 wpm)
Timeline
Health Smart MSO
09.2019 - 03.2026
Advance Medical Management (AMM)
09.2016 - 09.2019
MEDICAL PROFESSIONAL
03.2016 - 08.2016
ACCOUNTABLE HEALTH PLAN IPA
04.2006 - 03.2016
CLAIMS EXAMINER
UFCW
02.2005 - 12.2005
CLAIMS EXAMINER
WESTERN GROWERS
03.2004 - 12.2004
CLAIMS EXAMINER
UNIVERSAL CARE
03.2003 - 04.2006
CLAIMS EXAMINER
UNIVERSAL CARE
01.2002 - 12.2003
BILLER
PER'SE TECHNOLOGIES
12.1995 - 12.2001
Certification - Electronic Data
B.A. Degree - Business Education
Polytechnic University of the Philippines
High School Diploma - undefined
Southeastern College in the Philippines