Eduard Chavez
Summary
Claims Processing Team Lead with over 4 years of experience adjusting/reviewing medical claims and reports insuring accurate payment and processing as well as 4 years of Customer Service Experience. Strong creative and analytical skills. Diligent, detail oriented and resourceful in completing projects in a timely fashion.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Claims Processing Team Lead
Humana, Inc.
04.2023 - Current
- Lead a team of medical claims adjusters to review, process, and adjudicate claims with high accuracy and compliance.
- Assign claims based on complexity, provider type, and adjuster workload to ensure timely turnaround.
- Ensured compliance with HIPAA regulations, payer guidelines, and internal quality standards.
- Train and mentor new hires on claims systems and claim adjudication rules.
- Collaborate with and internal departments to resolve claim disputes and denials.
- Monitor team performance metrics (e.g., claims processed per day, accuracy rate) and implemented process improvements to reduce rework.
- Investigate and resolve high-cost or complex claims to control costs and prevent errors.
- Analyze claim trends to identify root causes of denials or delays, recommending corrective actions.
- Prepare weekly and monthly performance reports for leadership, highlighting productivity and compliance results.
Claim Processing Representative
Humana, Inc.
08.2021 - 04.2023
- Review and adjudicate complex or specialty claims, submitted either via paper or electronically
- Determine whether to return, deny, or pay claims following organizational policies and procedures
- Trained to process and adjudicate UB and HCFA claim forms and claim types such as: Outpatient, Inpatient, CAH, DPA, Home Health and more
- Experience with Humana systems: CAS, CIS PRO, CGX, Macess and DIG Toolbar
- Trained to process LOA's and create cases in CRM
- SME (Subject Matter Expert) certified
- Part of the Medicare Pricer Team
- Chosen to assist as a backup Team Lead for my knowledge in multiple processes as well as the willingness to assist in any way possible.
Escrow Assistant (Analyst)
Synergies
03.2018 - 04.2021
- Assisted Escrow officers in maintaining an organized schedule ensuring they met title insurance Closings
- Communicated daily with customers (Buyers, Sellers, Real Estate Agents, Etc.) via Email, Fax and phone to coordinate and confirm that all necessary real estate contract stipulations are met prior to closing
- Revised Title Reports to confirm all Title exceptions (Liens, encumbrances, Deeds of Trust, Mortgages) have been paid off and are cleared off title reports before providing title insurances
- Maintaining confidentiality of customer data, accounts, and non-public information.
CLERK
DOCIFARM | NATURAL SUPPLEMENT DISTRIBUTION CENTER
02.2017 - 02.2018
- Maintain filing, database systems, and inventories
- Communicate with clients and employees and respond to any queries or complaints
- Collect, count, and disburse money, do basic bookkeeping, and complete banking transactions.
Education
High School Diploma -
Politecnico Mexico
07.2013
Skills
- Proficient in the use of Microsoft suite (Word, Excel, SharePoint, Power Point, Outlook, Access and Teams),
- Excellent organizational skills
- Performing critical duties diligently to ensure goals are met
- Administrative experience
- Superb interpersonal skills that enable professional and cordial relationships with co-workers and potential clients
- Problem Solving
- Creative thinking
- Adaptability and flexibility
Additional Information
I am looking to further my career in the Hertel Claims Organization by bringing my talents and expertise to a Team Lead role.
Certification
SME Certification
Humana Inc. - Louisville, KY - February, 2023
Languages
English
Native or Bilingual
Spanish
Native or Bilingual
Cross-Functional Teams & Projects
- High Dollar Peer Review Team: Review and adjudicate Medicare/Medicaid Inpatient and Outpatient claims that reimburse $100,000 or more.
- Team Lead Process Improvement: Review / analyze process input from the different claims teams on the claims department in order to improve mentor processing guidelines.
- Overlay Team: Examine, sort and re-work claims that have overlapping member information to ensure accurate payment and policy coverage.
Timeline
Claims Processing Team Lead
Humana, Inc.
04.2023 - Current
Claim Processing Representative
Humana, Inc.
08.2021 - 04.2023
Escrow Assistant (Analyst)
Synergies
03.2018 - 04.2021
CLERK
DOCIFARM | NATURAL SUPPLEMENT DISTRIBUTION CENTER
02.2017 - 02.2018
High School Diploma -
Politecnico Mexico
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Adplatform<ul><li>Roles and Responsibilities</li><li>Hiring and team building</li><li>Managing team’s career progression and performance reviews</li><li>Managing Performance improvement plan and firing</li><li>Mentoring</li><li>Product roadmap planning and execution</li><li>Accountability of the entire delivery execution including the risk mitigation planning.</li><li>Stakeholder management</li><li>Adhering to Apple Privacy and Security Guidelines for platform</li><li>Design and implementation of new architectures and solutions to manage all online services for AdXchange in Apple Ads.</li><li>Design and implementation of new architectures and solutions deliver Budget experimentation in Apple Ads</li><li>Design and implementation of new architectures and solutions to manage data for Ad Platform.</li><li>Creating and maintaining all the data and analytics and revenue pipelines for Ad Platforms</li><li>Driving the solution for data ingestions and data processing across Ad platform</li><li>Defining the Strategy for data governance and data access</li><li>Collaboration with business to deliver relevant data and insight for our strategy and decisions.</li><li>Managing storage, processing, copy/synchronization etc. appropriate to scale</li><li>Enabling machine learning and algorithm groups by proving them right frameworks and data</li><li>Advancing team’s design methodology and quality programming practices and evangelize those techniques across Ad platform.</li><li>Deliveries</li><li>Setup 8+ member team to design and deliver Budget Allocation and Budget experimentation.</li><li>Leading Ad Delivery services team, responsible for delivering various capabilities like query understanding, targeting, fraud etc.</li><li>Delivered and Lead Design for observability for budget, and data platform in Ad platform.</li><li>Setup 11+ members high performing team to handle various business needs such as analytics and micro services for Display Advertising as well as Data Platform</li><li>Instrumental in driving Data Platform throughout the SDLC from inception, design, development, testing and deployment.</li><li>Instilled a strong team culture of high-quality delivery by constructive feedback, cross collaboration, focus and motivation.</li><li>Delivered Realtime and Batch Platform with various integrations</li><li>Delivered new DIP design for Data Platform</li><li>Delivered design of all the components of Data processing platform</li><li>Transitioned Display data work to India seamlessly and delivered many critical business impacting features and organizational security initiatives.</li><li>Closely worked with various stakeholders to understand the requirements which resulted into efficient remote work culture.</li><li>Seamless Display execution and set up best practices for 24X7 production on-call.</li><li>Tools and Technologies</li><li>AWS, S3, Kafka, Spark, Hadoop, EMR, Hive, Scoop, Flume, Cassandra, Airflow, Oozie, Gobblin, Schema Store, Icloud, Grafana, Kubernetes, Vertica, Alation, snowflake, druid, Iceberg, Java, Scala, IntelliJ, Oracle, MySql, Git, RIO, Spinnaker, Elastic cache, Grpc, Agile.</li></ul> at Apple - Adplatform