Guadalupe Luna
Eastvale,CA
Summary
Experienced with managing provider relationships to ensure seamless communication and satisfaction. Utilizes problem-solving skills and negotiation techniques to resolve conflicts and enhance service delivery. Knowledge of healthcare regulations and administrative processes, ensuring compliance and operational efficiency.
Overview
17
17
years of professional experience
Work History
Provider Relations Representative
CalOptima Health
06.2015 - Current
- Assisted providers in navigating through various reimbursement processes, resulting in timely payments and reduced financial disputes between parties.
- Strengthened provider networks through regular outreach and relationship building activities.
- Served as a liaison between healthcare organizations and insurance companies to ensure seamless communication regarding claims processing and payment matters.
- Managed high-volume caseloads of dispute resolution cases, providing swift resolutions that maintained positive relationships with both parties involved.
- Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.
- Contributed to and enhanced audit processes to maximize quality management standards.
- Organized and participated in provider workshops, seminars, and meetings to foster ongoing engagement with network partners.
- Provided exceptional customer service when working directly with healthcare professionals, establishing a reputation as a trusted resource for assistance.
- Collaborated with internal departments to resolve complex provider issues, maintaining positive relationships and open communication channels.
- Enhanced provider satisfaction by addressing and resolving inquiries in a timely manner.
Senior Claims Examiner
CalOptima Health
05.2014 - 06.2015
- Processed Medi-Cal claims
- Processed claims based on the contract agreements
- Reviewed claims for billing errors
- Manually corrected systematic errors prior to finalizing claims for reimbursement
- Adjusted claims for correct reimbursement
Claims Examiner
AllsWell Staffing
03.2014 - 05.2014
- Processed Medicare, Institutional, Dialysis and Professional claims
- Processed claims based on the contract agreement
- Reviewed claims for billing errors
- Manually corrected systematic errors prior to finalizing the claims for reimbursement
- Adjusted claims
Claims Examiner
Medical Professional Staffing
08.2013 - 01.2014
- Entered claims into the EZ Cap system
- Processed Institutional & Professional Claims
- Assisting the Authorizations Department by calling provider's office and obtaining medical records
Claims Processor
WellPoint, Anthem Blue Cross
11.2008 - 10.2012
- Managed high volume of claims, prioritizing tasks to meet deadlines without sacrificing quality.
- Reviewed and analyzed claims to ensure accuracy, completeness, and compliance with company policies.
- Managed workload and priorities to meet claims processing meet deadlines.
- Processed ITS claims (Electronic claims submitted by the Host Plan)
- Priced and Processed Outpatient/Inpatient
- Adjusted claims
Education
No Degree - General Education
Chaffey College
Rancho Cucamonga, CASkills
- Claims reviewing
- Health plan operations
- Provider support
- Strategic business relationships
- Educational presentations
- On-site visits
- Provider orientations
- Staff training and motivation
- Claims resolution
- Provider relations
- Teamwork
Languages
Spanish
Native or Bilingual
Timeline
Provider Relations Representative
CalOptima Health
06.2015 - Current
Senior Claims Examiner
CalOptima Health
05.2014 - 06.2015
Claims Examiner
AllsWell Staffing
03.2014 - 05.2014
Claims Examiner
Medical Professional Staffing
08.2013 - 01.2014
Claims Processor
WellPoint, Anthem Blue Cross
11.2008 - 10.2012
No Degree - General Education
Chaffey College
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