Erica Rising
Bellflower,CA
Summary
Senior claims specialist with extensive expertise in auditing and compliance management for Medicare and commercial plans. Proven track record of enhancing operational performance through effective communication and leadership in resolving complex claims issues. Skilled in optimizing processes and maintaining high organizational standards, contributing to excellence in service delivery.
Overview
19
19
years of professional experience
Work History
Senior Claims Specialist III
Optum Health Care
El Segundo, California
01.2017 - Current
- Managed nine Medicare and seven commercial plans, ensuring compliance and optimal performance.
- Reviewed monthly and quarterly timeliness reports to identify and address discrepancies across all plans.
- Collaborated with multiple departments to resolve claims-related issues.
- Prepared annual audit universes for health plan audits and re-audits.
- Assisted with DMHC MTR by analyzing paid provider denials and reviewing PDR reports for underpayments and overpayments.
- Conducted pre-audit preparations for DMHC audits, ensuring accurate member contract benefits.
- Reviewed CMS validation audit reports and submitted findings to quality control department.
- Maintained logs of recurring claims issues, facilitating resolution of MTRs and CAPs.
Claims Supervisor
Beacon Health Options
Cypress, California
02.2007 - 08.2017
- Manage all claims daily inventory count for all health plans, such as Aetna, Managed Health Net, Anthem Blue Cross, and all Medicare and Medicare accounts.
- Managed reprocessing requests, adjustments, recoupments, and interest adjustments for all health plans.
- Handled all the Health plan audits and retrieve all materials to complete the audits within a timely manner.
- Assisted with customer service calls from members and providers, resolving escalated issues efficiently.
- Acted as liaison among health plans, providers, and company to facilitate effective communication and operations.
- Handled over 450 calls a day and either did initial intake, created authorizations, or give members MD or therapist referrals.
- Scheduled urgent appointments for medical doctors and therapists, ensuring adherence to established time frame guidelines.
- Identify provider access problems on log that is reviewed by Network Development Committee.
- Received phone calls and voicemails after hours from patients, providers, and health plan representatives, and facilities, requesting complete screenings for Intake and Referrals.
Education
HealthCare Administration
University of Phoenix
Phoenix, Az01.2024
High School Diploma -
Lakewood High School
Lakewood, CA06.2003
Some College (No Degree) - General education
Long Beach City College
Long Beach, CASkills
- Typing speed 45 wpm
- Effective communication
- Team collaboration
- Time management
- Organizational abilities
- Leadership qualities
- Quick learner
- Auditing expertise
- Motivation techniques
- Data analysis
Timeline
Senior Claims Specialist III
Optum Health Care
01.2017 - Current
Claims Supervisor
Beacon Health Options
02.2007 - 08.2017
HealthCare Administration
University of Phoenix
High School Diploma -
Lakewood High School
Some College (No Degree) - General education
Long Beach City College