Diane Madrid
Indio,CA
Summary
Highly-motivated employee with desire to take on new challenges. Strong work ethic, adaptability, and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills. Committed job seeker with a history of meeting company needs with consistent and organized practices. Skilled in working under pressure and adapting to new situations and challenges to best enhance the organizational brand.
Overview
12
12
years of professional experience
Work History
Claim Examiner II
Desert Oasis Healthcare
Palm Springs, CA
01.2021 - Current
- Reviewed administrative guidelines whenever questions arose during processing of claims.
- Processed appeals from providers regarding denied claims.
- Input claim information and payments into company database.
- Developed strategies to reduce claim denials and improve overall claim performance.
- Tracked differences between plans to correctly determine eligibility and assess claims against benefits and data entry requirements.
- Used contract notes and processing manual to correctly apply group-specific classifications to claims.
- Conducted reviews of high dollar value complex cases involving multiple services rendered by different providers.
- Identified discrepancies in medical claims, contacted providers or other personnel as necessary to resolve issues, and corrected errors.
- Verified insurance eligibility of patients through online systems.
- Sent clinical request and missing information letters to obtain incomplete information.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Administered standard contract benefits to process pending claims for dental benefits.
Data Entry Clerk II
Desert Oasis Healthcare
Palm Spring, CA
03.2020 - 01.2021
- Maintained database by entering new and updated customer and account information.
- Transferred written information into databases to maintain consistent, accurate client records and project details.
- Utilized specialized software applications related to the job role.
- Verified outdated data and implemented necessary changes to records.
- Remained focused for lengthy periods to accurately perform work with adequate speed.
- Created reports and audited charts to maintain concise records.
- Kept detailed notes during meetings and relayed information to co-workers through email.
- Processed customer and account source documents by reviewing data for deficiencies.
- Input client information into spreadsheets and company database to provide leaders with quick access to essential client data.
- Compiled reports based on gathered information.
- Obtained scanned records and uploaded into company databases.
- Identified discrepancies between source documents and entered data.
- Followed up on pending tasks until completion.
- Created spreadsheets to track data entries.
- Scanned documents into appropriate databases for storage purposes.
- Performed data entry from paper documents, emails, and other sources into computer systems.
Claims Integrity Specialist
Desert Oasis Healthcare
Palm Springs, CA
11.2019 - 03.2020
- Documented all findings from audit reviews and maintained an up-to-date log of activities performed.
- Performed audits on patient accounts for compliance with federal, state, and local regulations.
- Evaluated medical records for accurate code assignment based on ICD-10 guidelines.
- Drafted letters of explanation for customers regarding dispute resolutions.
- Conducted studies of appeals procedures to confirm adherence to legal requirements while facilitating disposition of cases.
- Trained new staff members on proper dispute resolution techniques.
- Investigated complex cases involving multiple parties and and or large amounts of money.
- Performed periodic reviews of customer accounts to identify any discrepancies.
- Assisted customers with dispute resolution by providing helpful advice on how to resolve their issues.
- Provided guidance on best practices for resolving disputes in a timely manner.
- Understood and followed oral and written directions.
Claims Examiner II
Desert Oasis Healthcare
Palm Springs, CA
08.2011 - 11.2019
- Based payment or denials of medical claims upon well-established criteria for claims processing.
- Accurately processed large volume of medical claims every shift.
- Conducted secondary evaluations of original investigations documentation and reports to facilitate smooth resolutions.
- Analyzed provider contracts to ensure proper reimbursement levels were achieved.
- Researched medical records to identify additional information needed for processing claims.
- Prepared detailed reports outlining findings and trends in claim processing activities.
- Provided training and guidance to new staff members on procedures related to claim processing.
- Monitored accounts receivable aging reports to ensure timely payments from payers.
- Reviewed claims for accuracy before submitting for billing.
- Interacted with providers regarding claim status or other related issues as required.
- Gathered and documented evidence to support court proceedings.
- Inputted data into the system, maintaining accuracy of provider coding information and reported services.
- Conducted periodic reviews of rejected and denied claims to identify patterns or trends in rejections.
- Tracked differences between plans to correctly determine eligibility and assess claims against benefits and data entry requirements.
- Administered standard contract benefits to process pending claims for dental benefits.
- Explained loss coverage, assisted policyholders with itemizing damages and coordinated alternative living arrangements.
- Ensured HIPAA compliance by maintaining strict confidentiality of patient information.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Input claim information and payments into company database.
- Validated that all necessary documentation was included with each claim submission.
- Determined the appropriate payment amount based on contractual agreements with providers.
- Verified insurance coverage and eligibility of patients for services rendered.
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Assisted with customer requests and answered questions to improve satisfaction.
- Completed day-to-day duties accurately and efficiently.
Education
Vocational Trade - Medical Coding And Billing
Milan Institute - Palm Desert
Palm Desert, CA06-2010
High School Diploma -
Amistad High School
Indio06-2000
Skills
- Policy Investigations
- Decision-Making
- Team Collaboration
- Complex Mathematics
- Critical Thinking
- Claims Processing
- Claims Evaluation
- Computer Skills
- Report and Records Review
- MS Office
- Payment Processing
- Benefit Explanation
- Body Panel Repair
- Invoice Processing
- Data Entry
- Auditing
- Financial Reporting
- DME Processing
- Anesthesia Processing
- Dialysis Processing
- Skilled Nursing Claim Processing
- Out Patient and Inpatient Hospital Claims
- Radiology Processing
Timeline
Claim Examiner II
Desert Oasis Healthcare
01.2021 - Current
Data Entry Clerk II
Desert Oasis Healthcare
03.2020 - 01.2021
Claims Integrity Specialist
Desert Oasis Healthcare
11.2019 - 03.2020
Claims Examiner II
Desert Oasis Healthcare
08.2011 - 11.2019
Vocational Trade - Medical Coding And Billing
Milan Institute - Palm Desert
High School Diploma -
Amistad High School