Diane Madrid
Indio,CA
Summary
Proven Claims Specialist with a track record of enhancing customer satisfaction and streamlining claim processes at Desert Oasis Healthcare. Expert in claims analysis and critical thinking, adept at prioritizing work and maintaining meticulous attention to detail. Achieved significant improvements in claim resolution efficiency by leveraging skills in policy interpretation and claims processing.
Overview
13
13
years of professional experience
Work History
Full Risk Claims Specialist
Hill Physicians Medical Group
San Ramon, CA
01.2024 - Current
- Enhanced customer satisfaction with timely communication, empathy, and clear explanations of claim outcomes.
- Managed a high volume of claims effectively by prioritizing tasks and maintaining excellent organizational skills.
- Developed strong working relationships with external partners such as adjusters, legal counsel, and medical professionals to facilitate efficient claim resolution processes.
- Responded to inquiries by answering questions, providing information and directing customers to appropriate resources.
- Reviewed new files to determine current status of injury claim and to develop plan of action.
- Optimized work processes within the team by sharing best practices for evaluating evidence, validating coverage eligibility, and determining loss values.
- Reviewed insurance and claims documents to verify required information and secure any missing data for settlements.
- Checked documentation for accuracy and validity on updated systems.
Claims Examiner II
Desert Oasis Healthcare
Palm Springs, CA
01.2021 - 01.2024
- Handled sensitive information with discretion, ensuring confidentiality of personal and financial details for claimants throughout the claims examination process.
- Utilized analytical skills to evaluate medical bills for accuracy and appropriateness of charges before approving payments as part of the claims process.
- Participated in cross-functional team meetings to address organizational challenges related to claims management and develop solutions collaboratively.
- Reduced claim processing time by implementing efficient workflow strategies and prioritizing tasks effectively.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
Data Entry Clerk
Desert Oasis Healthcare
Palm Springs, CA
03.2020 - 01.2021
- Completed data entry tasks with accuracy and efficiency.
- Followed established procedures to enter and process data correctly.
- Organized, sorted, and checked input data against original documents.
- Scanned documents and saved in database to keep records of essential organizational information.
- Sorted documents and maintained organized filing process.
- Created and maintained data entry logs to track data entry activities.
- Developed data entry policies and procedures in compliance with company standards.
Claims Integrity Specialist
Desert Oasis Healthcare
Palm Springs, CA
11.2019 - 03.2020
- Followed all company policies and procedures to deliver quality work.
- Developed strong client relationships through consistent communication and attentive service.
- Improved customer satisfaction rates through proactive problem-solving and efficient complaint resolution.
- Interpreted clients' needs and introduced services to fit specific requirements.
- Gathered, organized and input information into digital database.
- Maintained database systems to track and analyze operational data.
Claim Examiner II
Desert Oasis Healthcare
Palm Springs, CA
08.2011 - 11.2019
- Ensured compliance with state regulations by conducting regular audits of claim files and documentation.
- Assisted policyholders in understanding their coverage options, guiding them through the claims process stepbystep.
- Reduced claim processing time by streamlining workflow and prioritizing tasks efficiently.
- Handled account payments and provided information regarding outstanding balances.
- Managed invoicing and payment processing operations.
- Adapted quickly to changes in company policies or procedures, maintaining consistent performance levels during periods of transition.
- Kept management informed of account statuses through regular reports detailing outstanding balances and collection efforts, supporting informed decision-making processes.
- Entered and maintained billing information in company internal databases for accessibility.
- Developed and implemented billing procedures to enforce compliance with company policies.
- Reduced late payments through consistent communication with clients and proactive problem-solving efforts.
Education
High School Diploma -
Amistad High School
Indio, CA06.2020
No Degree - Medical Coding And Billing
Milan Institute - Palm Desert
Palm Desert, CA06.2010
Skills
- Claims
- Claims Processing
- Claims Investigation
- Verbal Communication
- Policy Interpretation
- Claims analysis
- Critical Thinking
- Customer Service
- Organizing and Prioritizing Work
- Attention to Detail
- Insurance Coverage Verification
- Claim Amount Calculations
- Data Entry
- Medical Terminology
- 10-Key Touch
- DME Processing
- Dialysis Processing
- Skilled Nursing Claim Processing
- Out and Inpatient Hospital Claims
- Anesthesia Processing
- Auditing
- Radiology Processing
Timeline
Full Risk Claims Specialist
Hill Physicians Medical Group
01.2024 - Current
Claims Examiner II
Desert Oasis Healthcare
01.2021 - 01.2024
Data Entry Clerk
Desert Oasis Healthcare
03.2020 - 01.2021
Claims Integrity Specialist
Desert Oasis Healthcare
11.2019 - 03.2020
Claim Examiner II
Desert Oasis Healthcare
08.2011 - 11.2019
High School Diploma -
Amistad High School
No Degree - Medical Coding And Billing
Milan Institute - Palm Desert