Dushka Balta

• Claims – Provider Appeals & Grievance and Ancillary
• Hire, inspire, motivate, coach, counsel and supervise staff, monitor performance of employees
• Conduct annual performance review · Supervise adjustments (appeals) in multiple systems (ABS/Macess, Amisys/CenPAS), production, quality and related reports, and runs and reviews reports as necessary
• Conduct bi-weekly and one-on-one meetings
• Assess and allocate work volumes on daily basis
• Special project work as assigned
• Ensure task completion and performance goals are met, such as Quality, Adherence, service levels
• Ensure that Appeals and Grievance processes all cases in accordance with policies and procedures
• Identify and resolve operational problems
• Implements changes as appropriate, monitors performance on an on-going basis, and addresses any related issues
• Accountable for daily/weekly/monthly activities of all team members
• Directs and conducts training of new associates
• Develops and maintains effective business relationships with internal and external clients
• Accountable for approving interest up to $400 and reviewing all interest forms over $400 prior to sending to Management for signature approvals
• Supports the staff with any technical questions, analyzes pertinent data and make decisions with minimal supervision
• Audit staff to standards and provide continuous feedback
• Assist management in regulatory audits
• Create training material for new hires / new products
• Manage Medicare Monitored workflow to improve employee time management and increase productivity
• Enforced rules and regulations outlined in company manual to set forth expectations comprehensibly and consistently
• Generated reports detailing findings and recommendations
• Review monthly internal Audits

LEAD CLAIMS ANALYST 03/2009 to 10/2013 Health Net of CA, Woodland Hills, CA

• Assists and supports Claims Supervisor with day-to-day functions of the team to include monitoring and helping manage inventory to comply with departmental goals
• Accountable for approving interest up to $200 and reviewing all interest forms over $200 prior to sending to Management for signature approvals
• Reports a root cause of adjustments and facilitates corrective actions as needed
• Maintains and updates knowledge of all claims products, contracts and standard reference materials
• Supports staff with any technical questions, analyzes pertinent data and make decisions with minimal supervision
• Assists in training of new hires including a review of internal audits with new hires and existing staff
• Processes all adjustment issues, as they occur, to comply with company service standards to ensure achievement of company goals
• Researches/adjusts all difficult, complex requests for overpayment, underpayment, refund, contract issues, and stop loss to ensure compliance with departmental and company policies and procedures
• Determine the level of reimbursement based on established criteria; contracts, plans and employer groups
• Develops and maintains effective business relationships with internal and external clients
• Performs special projects as assigned and resolves high profile escalated issues
• Ensures compliance with government regulations and requirements (DMHC, DOI, CMS).

CLAIMS ADJUSTER III 04/2006 to 03/2009 Health Net of CA

• Provider Appeal & Grievance
• Responsibilities included but were not limited to the following:
• Researches/adjusts all requests for overpayment, underpayment, refund, and contract issues to ensure compliance with departmental and company policies and procedures
• Conducts cost containment analyses · Processes all adjustment issues, as they occur to comply with company service standards and to ensure achievement of company goals
• Determines level of reimbursement based on established criteria: contracts, plans, and employer groups
• Maintains/updates knowledge of all claims products, contracts and standard reference materials
• Develops/maintains effective business relationships with internal and external clients
• Ensures compliance with government regulations and requirements

Review appeals and complaints; researches any missing or required information

• Meet daily production in timely manner .Responded by in writing to providers to process and resolve the claim issue
• Processed all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner
• Assist colleagues with their appeals and provide feedback
• Review and process Medicare Advantage appeals
• Prepare packets for Maximus Federal Services

MULTI- PRODUCT CLAIMS EXAMINER 03/2003 to 06/2006 Health Net of CA

• Examine and process multi products, such as · HMO, FLEX, POS, CSP, PPO and Health Families
• Determine level of reimbursement based on provider contract, plan and employer group provisions
• Meet daily production in timely manner
• Re-evaluate all decision with supervisor and/or supportive staff
• Document provider claims/billing forms to support payments/decisions
• Match authorizations to claims, and maintains current desk procedural and reference materials
• Performs special projects as assigned (i.e EOB Redesigned Project)
• Assist colleagues with their claims and their pend reports
• Processes adjustment issues, as they occur to comply with company service standards and to ensure achievement of company goals
• Maintain updated knowledge of all claims products, contracts and standard reference materials
• Process Hemodialysis/ Chemotherapy claims.

• Established performance metrics for the team, consistently tracking progress towards goals and making adjustments as needed.
• Evaluated employee performance and coached and trained to improve weak areas.
• Responsible for budgeting, planning, hiring new employees, pay rolls and monthly accounting