Gina Moreno
San Antonio,TX
Summary
Qualified Claims Examiner and Claims Support Specialist versed in investigating claims, verifying information and highly experienced in claims processing and claim auditing. Friendly and upbeat team player with organized and disciplined approach. Offering 24 years of insurance experience.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Claims Support Specialist
Healthsmart Benefit Solutions
08.2016 - Current
- Worked productively in fast-moving work environment to process large volumes of claims.
- Analyzed and addressed escalated claims to resolve issues quickly.
- Collaborated with internal departments and external vendors to achieve fast resolution of claims.
- Followed up with customer service department on unresolved issues.
- Researched and analyzed complex claims to determine next steps and possible outcomes.
- Maintained accurate and up-to-date records of claim information for future reference.
- Examined reports, accounts, and evidence to determine integrity and accuracy of information.
- Prepared and presented detailed reports to management on claims issues to aid in decision making.
- Developed and implemented strategies to improve claim processes.
- Generated, posted and attached information to claim files.
- Provide monthly audit results to manager in regards to completed examiner processed claims and incoming customer service transmittal calls.
Claims Examiner
Healthsmart Benefit Solutions
08.1999 - Current
- Paid or denied medical claims based upon established claims processing criteria.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Verified patient insurance coverage and benefits for medical and dental claims.
- Managed large volume of medical claims and dental claims on daily basis.
- Monitored and updated claims status in claims processing system.
- Reviewed provider coding information to report services and verify correctness.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Identified and resolved discrepancies between patient information and claims data.
- Responded to correspondence from insurance companies.
- Followed up on denied claims to verify timely patient payment and resolution.
- Researched and resolved complex medical claims and dental claim issues to support timely processing.
Education
BACHELOR OF BUSINESS MANAGEMENT - BACHELOR OF BUSINESS MANAGEMENT
UNIVERSITY OF PHOENIX
Phoenix, AZ12.2024
High School Diploma -
Mccollum High School
San Antonio, TX05.1991
Skills
- Medical Terms and Procedure Knowledge
- Policy Requirements and Eligibility
- Learning Strategies
- ICD Codes
- HCPCS Codes
- CPT Codes
- UB92 Bills
- HCFA Bills
- Dental Bills
- Medical Terminology
- Benefits Guidelines
- Insurance Coverage Limits
- Critical Thinking
- Knowledge of HIPAA Regulations
- Customer Service
- Health Insurance Industry Knowledge
- Policy and Procedure Explanations
- Microsoft Office
- Report and Records Review
- Customer Inquiries
- Time Management
- Project Requirements
- Great Mathematical Skills
- Creative Solutions
- Production Goals
- Special Projects
- Claims Adjustments
- Active Listening
- Team Meetings
- Information Updates
- Special Handling
- Complex Problem-Solving
- Rim System
- Quicklink System
- Document Uploading
- 10-Key Touch
Accomplishments
I have built a good rapport with our external PPO networks. I work closely and professionally with them when consulting on issues, rush repricing or delay in returns. I work together with them on ways to improve the delay repricing and how we could help one another. This process has helped their turn around time from 30 days to 14 days.
Certification
- Dean Vaughn medical terminology 1,2,3, Anthem - 1996
Timeline
Claims Support Specialist
Healthsmart Benefit Solutions
08.2016 - Current
Claims Examiner
Healthsmart Benefit Solutions
08.1999 - Current
BACHELOR OF BUSINESS MANAGEMENT - BACHELOR OF BUSINESS MANAGEMENT
UNIVERSITY OF PHOENIX
High School Diploma -
Mccollum High School
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