Elizabeth Dawn Gaona
Summary
Detail-oriented Examiner with 28 years of experience with Medicare Advantage and Commercial lines of business. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
28
28
years of professional experience
Work History
Claims Examiner
Arizona Priority Care
11.2019 - Current
- Assisted in the training and onboarding of new team members, sharing knowledge and best practices to ensure their success.
- Verified patient insurance coverage and benefits for medical claims.
- Managed large volume of medical claims on daily basis.
- Identified and resolved discrepancies between patient information and claims data.
- Monitored and updated claims status in claims processing system.
- Paid or denied medical claims based upon established claims processing criteria.
- Supported team members during periods of high workload, providing guidance on challenging cases or offering assistance when needed.
- Maintained compliance with industry regulations and company policies while evaluating medical claims for accuracy and legitimacy.
- Generated reports on medical claims processing activities and results.
Provider Appeals Auditor
United Health Care
03.2016 - 06.2019
-
- Maintained confidentiality, handling sensitive information discreetly throughout all stages of the audit process.
- Followed established auditing processes to meet internal and regulatory requirements.
- Mentored junior auditors, sharing knowledge and best practices to foster their professional growth within the team.
- Back up lead as needed
- Assist team with questions.
- Provided detailed documentation on audit findings, facilitating swift corrective action when necessary.
- Conducts audits for NICE and COSMOS in multiple regions
- Provides feedback to reduce errors
Quality Claims Auditor
UnitedHealth Care
01.2008 - 01.2016
- Conducts audits for NICE and Iliad claims in multiple regions
- Provides feedback to examiners to reduce claim errors
- Special projects as assigned
- Assist in training and feedback with auditors.
Data Loading Analyst
PacifiCare
01.2001 - 01.2008
- Review, research, verify and enter contract information for existing and new providers
- Update provider information as requested
- Load information as requested for in and out of state providers
- Follow up on all correspondences with other departments
- Special projects and other duties as assigned
- Assists with BSL/admin duties as needed.
Associate Claims I
PacifiCare
01.2000 - 01.2001
- Examine and adjudicate claims
- Research and adjust claims
- Special projects
- Daily production reports
- Contact Provider office's for additional information when necessary
- Assist other teams to meet common goals.
Front Office Support
Arizona Cardiology Group
01.1999 - 01.2000
- Greeting and checking in daily patients
- Answering incoming phone calls and distributing messages and calls to the appropriate person
- Scheduling appointments
- Obtaining authorizations for office visits and procedures
- Updating and entering all patient information
- Medical records.
Managed Care- Referrals
Catholic Healthcare West
01.1998 - 01.1999
- Obtain authorizations from various insurance companies for patients to go to specialist in network
- Communications with outside specialist and office staff
- Communication to patients regarding their authorization and acting as a liaison between the physicians, nurses and patients
- Maintaining computer as well as computer logging and tracking of patient referrals
- Back up phone representative as needed.
Center Assistant
Talbert Medical Center
01.1996 - 01.1998
- Lead Support Staff Service Specialist
- Acting liaison between support staff, management and physicians
- Assist billing department with coding and data entry
- Cash control
- Account payable and payroll preparation
- Supply ordering
- Maintaining contact with outside vendors and pharmacy representatives
- Assisted providers and management with some secretarial duties as requested
- Support Staff Specialist: Greeted and checked in patients
- Answered phones, took messages and distributed incoming calls to the appropriate staff
- New patient registration, insurance set up, and insurance verification
- Chart preparation.
Education
GED -
Maricopa Community Colleges - Phoenix College
Phoenix, AZ05.1997
Skills
- Claims Processing
- Verbal Communication
- Data Verification
- Microsoft Office Suite
- Computer Skills
- Claims Evaluation
- Decision-Making
- Customer service and support
- Payment Processing
- Critical Thinking
- Claims
- MS Office
- Team Collaboration
- Claims adjustment
- Policy Interpretation
Medical Profile
- Detail-oriented claims auditor with diverse claims and quality assurance background, experience includes:
- Claim auditing in Medicare and Commercial business
- Claim processing in Medicare and Commercial business
- Error trending and analysis
- Root cause analysis
- Provider contract loading and research
- Proficient Microsoft Excel, Access, Word, and PowerPoint Member Eligibility Authorization Verification
References
Personal reference upon request
Timeline
Claims Examiner
Arizona Priority Care
11.2019 - Current
Provider Appeals Auditor
United Health Care
03.2016 - 06.2019
Quality Claims Auditor
UnitedHealth Care
01.2008 - 01.2016
Data Loading Analyst
PacifiCare
01.2001 - 01.2008
Associate Claims I
PacifiCare
01.2000 - 01.2001
Front Office Support
Arizona Cardiology Group
01.1999 - 01.2000
Managed Care- Referrals
Catholic Healthcare West
01.1998 - 01.1999
Center Assistant
Talbert Medical Center
01.1996 - 01.1998
GED -
Maricopa Community Colleges - Phoenix College
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