Deborah Araiza
Riverside,CA
Summary
Organized and detail-oriented Investigator dedicated to improving efficiency, productivity and profitability through continuous process improvement. Analytical thinker skilled at developing innovative solutions to complex problems. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
45
45
years of professional experience
Work History
Claims Adjuster
County of Riverside
12.2013 - Current
- Maintained knowledge of benefits claims processing, claims principles, medical terminology and procedures
- Paid or denied medical claims based on established claims processing criteria
- Responded to correspondence from insurance companies
- Reviewed provider coding information to report services and verify correctness
- Processed EDI claims
- Processed Multi-Plan claims
- Coordinated Benefits with other Medical Plans
- Reviewed insurance claims and member eligibility to determine overpayment trends and noncompliance issues
- Prioritized daily tasks to satisfy workloads and department's turnaround goals
- Researched issues related to claims processing to identify origins and implement corrective solutions
- Did customer service from providers to solve issues with claim status or check tracers
- Customer service from patients with questions on their claims helped them resolve issues.
Senior Claims Processor - Temp Assignment
Memorial Care
06.2013 - 12.2013
- Adjudicate various claim types, follow up for proper coding per Insurance Carriers & Calm guidelines and reimbursements
- Submit CIFS/SARS/TARS as needed, Analyze and review patient for correct payments, accountable for reducing delinquency for assigned accounts
- Solve all collection issues, process refunds, resolve client discrepancies and short payments
- Did electronic and paper billing an claim processing.
Collector claims processor
CASA COLINA HOSPITAL
06.2009 - 06.2013
- Patient Accounting
- Work patient accounts & TARS, review claims for proper coding per Calm guidelines
- Electronic Calm & Commercial claims processing
- Provide customer Service as needed
- Take payments from patients and review accounts.
Provider Resolutions Specialist
HELPMATES STAFFING/CAL-OPTIMA
02.2009 - 06.2009
- Help resolve issues on claims for provider disputes, answer phone calls from providers
- Advise providers of proper billing and coding procedures for proper reimbursements, according to MediCal and Medicare guidelines.
Claims Examiner
Temp Service
06.2008 - 02.2009
- Adjudicate various claim types, review claims for proper coding and documentation, process claims with correct reimbursements
- Maintain high standards in accuracy and daily quotas above expectation.
Claims Auditor
RIVERSIDE MEDICAL CLINIC
03.2006 - 06.2008
- Audit various claims for proper coding, payment, timeliness to Insure all claims met compliance and proper coding issues
- Make sure all claims meet proper policy and procedures set by the department guidelines.
Claims Manager
PPMC, Inc
01.2005 - 02.2006
- Oversee the claims department, production, attendance, daily staff situations, payroll, check runs, make sure the office is up to par with computer system, compliance issues, establish department policies and procedures
- Review all staff making sure they meet standards and quotas
- Adjudicate claims when necessary for compliance
- Staff meetings and interview/train new employees.
Claims Processor
Temp Service
01.2005 - 08.2005
- Adjudicate professional & hospital claims
- Review & audit spread sheets for proper coding, & payments
- Maintain accuracy for reimbursements to medical providers meet high standards in daily quotas.
Senior Claims Processor
INLAND HEALTH ORGANIZATION
01.2000 - 12.2004
- Adjudicate various claim types Review & audit claims for proper coding, diagnosis & timely billing
- Maintain accuracy in reimbursement to medical provider & facilities Meet high standards in daily quotas.
Sr. Collector
LOMA LINDA UNIVERSITY HEALTH CARE
01.1997 - 01.2000
- Systematically analyzes and audits accounts for current balance, proper follow-up and maximum reimbursements
- Receives and resolves phone issues and questions
- Identifies misapplied payments, transfers/refunds, Monitor and resolves collection issues on high dollar accounts, work special projects for Senior Manager Do charge corrections for unit and train new employees.
Sr. Claims Processor
AETNA HEALTH PLAN
01.1992 - 01.1997
- Adjudicate various claim types Review claims for proper coding and documentation Process claims with correct reimbursements Maintain high standards in accuracy and daily quotas above and beyond what is expect Train new employees on the Managed Care System
Claims Department Team Leader
ELLIOTT EDES M.D
01.1989 - 01.1992
- Oversee the claims department, train new employees, Post charges and payments on computer Monitored and resolved collection issues Work proficiently in multiple areas Meet regularly with Doctor to discuss improvements and flow.
Claims Processor
BLUE CROSS
01.1979 - 01.1989
- Data enter claims in CRT
- Adjudicate all claim types, COB claims Met daily quotas Review CPT codes and documents.
Education
RN Pre-Req
Riverside City College
Riverside, CARN Pre-Req
San Bernardino Valley College
San Bernardino, CAWorkers Compensation Certified
IEA
12.2023
Skills
- Claims Investigation
- Highly motivated
- Claims Processing
- Advanced oral and written communication skills
Timeline
Claims Adjuster
County of Riverside
12.2013 - Current
Senior Claims Processor - Temp Assignment
Memorial Care
06.2013 - 12.2013
Collector claims processor
CASA COLINA HOSPITAL
06.2009 - 06.2013
Provider Resolutions Specialist
HELPMATES STAFFING/CAL-OPTIMA
02.2009 - 06.2009
Claims Examiner
Temp Service
06.2008 - 02.2009
Claims Auditor
RIVERSIDE MEDICAL CLINIC
03.2006 - 06.2008
Claims Manager
PPMC, Inc
01.2005 - 02.2006
Claims Processor
Temp Service
01.2005 - 08.2005
Senior Claims Processor
INLAND HEALTH ORGANIZATION
01.2000 - 12.2004
Sr. Collector
LOMA LINDA UNIVERSITY HEALTH CARE
01.1997 - 01.2000
Sr. Claims Processor
AETNA HEALTH PLAN
01.1992 - 01.1997
Claims Department Team Leader
ELLIOTT EDES M.D
01.1989 - 01.1992
Claims Processor
BLUE CROSS
01.1979 - 01.1989
RN Pre-Req
Riverside City College
RN Pre-Req
San Bernardino Valley College
Workers Compensation Certified
IEA
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