Ekaterina Katia Martikainen
Rosemead,CA
Summary
Detail-oriented Medical Claims Quality Assurance Auditor with over 8 years of experience in claims processing and auditing, specializing in accuracy and payment integrity. Expertise in identifying discrepancies, overpayments, and compliance issues ensures strict adherence to state, federal, and health plan regulations. Proficient in preparing comprehensive audit reports and recommending corrective actions while effectively collaborating with cross-functional teams to enhance operational efficiency and mitigate financial risks. A commitment to excellence drives continuous improvement in claims management processes and outcomes.
Overview
9
9
years of professional experience
Work History
Claims Quality Assurance Auditor
PIH HEALTH PHYSICIANS
12.2023 - Current
- Audit claims for accuracy, completeness, and compliance with company policies, industry regulations, and payer guidelines.
- Identify errors, inconsistencies, and potential fraud in claim data and adjustments, and determine their root causes
- Document findings, provide feedback for corrections, compile reports on quality metrics, and monitor key performance indicators
- Stay informed about and ensure adherence to relevant state and federal regulations, and payer-specific rules.
- Work with claims adjusters, management, and other internal and external customers to resolve issues and request information.
- Assist in training staff on quality standards and provide technical support or expertise as needed.
Senior Claims Examiner
PIH HEALTH PHYSICIANS
01.2021 - 11.2023
- Process all level of claims including Professional, Facility, COB, surgery, skilled nursing, lab, Home Health, ER, hospital (in and outpatient), DME, Pharmacy and radiology claims by applying claims processing guidelines and company policies and procedures.
- Analyze complex claim issues and handle all adjustments for corrected claims or when additional information previously requested is received.
- Identify and pend claims that require referrals to all support areas (eligibility, Medical management etc.) for evaluation or correction of data, tracking these claims to ensure that they are returned and resolved within regulatory guidelines.
- Review, develop and follow-up on senior non-contracted claims in timely manner
- Daily monitor of PDS (Prior Date Stamp for Senior) claims, request force payments to ensure compliance
- Other duties as assigned and delegated by the Management
Claims Examiner II
NETWORK MEDICAL MANAGEMENT
07.2020 - 12.2020
- Performing thorough review of pended claims for billing errors and/or questionable billing practices that might include duplicate billing and unbundling of services.
- Correcting system generated errors manually prior to final claims adjudication.
- Processing Health Plan demand claim and respond back to health plan after claim has been paid. Process provider dispute claim and any special project assigned by management team.
- Email Benefits, eligibility, contracting or Terms and Conditions if rate is incorrect when auditing
- Processing claims based upon the provider’s contract/agreements or pricing agreements, applicable regulatory legislation, claims processing guidelines and company policies and procedures.
- Process provider dispute claim and any special project assigned by management team.
- Validating eligibility and other possible health insurance coverage on the claims
Claims Examiner I
NETWORK MEDICAL MANAGEMENT
11.2016 - 07.2019
- Customer service duties
- Answering phone calls and providing claim status to providers
- Adjudication of claims: Special project claim, Health plan demand letters, Hospital and Medicare/Medi-Cal claims
- Applying all claims policies, contracts, practices and keeping in compliance with industry regulations and guidelines
- Confirm eligibility for claim billed and date of service
- Match and link authorization for required claim.
- Knowledge in applying health plan benefit matrixes and Division of financial responsibility
- Help auditing and assigning work to others
Education
High school diploma -
Turun Iltalukio
01.2009
Skills
- The ability to analyze data, identify trends, and draw meaningful conclusions
- Meticulousness to ensure accuracy in complex claim data and documentation
- Strong understanding of medical terminology, coding (eg, CPT, ICD-10), and their application in claims
- Knowledge of insurance guidelines, benefit plans, and how they apply to claims
- Effective written and verbal communication to provide feedback, answer questions, and collaborate with others
- Familiarity with claims management systems and other relevant software
- Understanding of relevant healthcare regulations and policies
- Ability to resolve discrepancies and issues by investigating and implementing corrective actions
Timeline
Claims Quality Assurance Auditor
PIH HEALTH PHYSICIANS
12.2023 - Current
Senior Claims Examiner
PIH HEALTH PHYSICIANS
01.2021 - 11.2023
Claims Examiner II
NETWORK MEDICAL MANAGEMENT
07.2020 - 12.2020
Claims Examiner I
NETWORK MEDICAL MANAGEMENT
11.2016 - 07.2019
High school diploma -
Turun Iltalukio
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