Irma C. Pantoja
Rowlett,TX
Summary
Experienced healthcare professional with 15+ years in the industry. Strong background in Health-rule Payor and Claim's Adjudication and Processing, Claims Auditing, and extensive knowledge of Medical Terminology, CPT codes, and ICD-10. Well-versed in the entire Claim's Revenue Cycle Process, including Prior Authorization, Claims Creation, Claim Submission, and Denied Claims Management. Dedicated team player with a collaborative mindset. Hard-working, driven, and embraces challenges. Demonstrated excellent time management skills and a strong work ethic. Results-oriented Specialist prepared to support organizational goals through collaborative efforts and adaptive strategies. Excellent communication and analytical skills ensuring seamless operations and consistent outcomes. Thorough team contributor with strong organizational capabilities, experienced in handling multiple projects simultaneously while ensuring accuracy. Effective task prioritization and meeting deadlines are among my strengths. Proactive approach to identifying and addressing issues with a focus on optimizing processes and supporting team objectives.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Lead Claim’s Specialist/Trainer
Dell Services/NTT Data
01.2013 - 05.2024
- Coordinated with IT to test new edits and create written processes for adjudicated claims
- Responsible for the manual pricing and calculation of all medical, dental and hospital claims that could not be adjudicated by the claim processing system
- Lead person for mentoring and training Claim Adjudicators on claim denials and appeals
- Created job aids and written manuals that would assist team on claim pricing calculations and medical guidelines
- Delegated weekly Root Cause meetings with multiple clients and management to determine best course of action on claim related, system and production concerns
- Provided feedback to management on departmental activities, to ensure Medicare compliance on ten BlueCross BlueShield Medicare Advantage Health Plans
- Served as the Subject Matter Expert leading and answering specific, claim and audit questions for several departments using an internal online tool
- Back-up to Supervisor and Management as needed
- Go to person to lead special projects for clients when necessary
Lead Quality Assurance Specialist
Dell Services/NTT Data
01.2013 - 07.2021
- Performed pre-pay, post-pay and system audits on Medicare Advantage claims in the IKA and NASCO System for Local Medicare Advantage and ITS Blue-card claims for several clients
- Performed complex quality audits for 30 Processors and 15 Auditors
- Audited High Dollar claims and provided management and clients with a detailed error report daily
- Developed formal written reports and communicated audit results to management and clients on a daily basis to target claim processing errors
- Responsible for Root Cause meetings and assessment of Claim errors and resolutions
- Researched audit reports for accuracy and responded to audit appeals
- Trained new Auditors on how to manually price all Inpatient, Outpatient and Professional claims using Medicare (CMS) Pricers
Claims Unit Lead /Trainer II
Trailblazer Health Enterprises, LLC
10.2006 - 12.2012
- Processed Medicare Hospital and Professional claims
- Analyzed, researched and corrected claims in return to provider (RTP) status per Medicare guidelines
- Reprocessed Inpatient and Outpatient claims that include DRGs and Outliers
- Responsible for rewriting departmental internal and external written claim’s work instructions for claim pends and claim processing edits
- Supervised three different teams of Claims Examiners to ensure claim production was being met in a timely manner to meet CMS processing requirements
- Attending CMS monthly meetings to discuss an operational plan for Change Requests and Transmittal plan process
- Served as liaison between Claims department and CMS on claim and system issues as well as quality updates done on a quarterly basis
- Assisted management with review and changes to SAS audits and other type of audits that would be sent from CMS
- System tester on new system pends and edits as well as claim changes before going into production
Provider Relations Specialist
Blue Cross and Blue Shield of Texas, Inc.
07.1996 - 07.2006
- Assisted providers/hospitals in resolving claim appeals and inquiries related to pricing, in the NASCO system
- Responded to claim-related, email questions from Providers regarding claim pricing and benefit contract issues
- Obtained referrals and pre-authorizations as required for procedures
- Answered questions on incoming calls regarding claims and corrected any billing errors from Providers
- Created training workshops for Hospital and Professional Providers on claim billing guidelines and how to bill and code claims correctly
Education
High School -
Lubbock High School
Lubbock, TexasHealthcare Management Associate Degree -
Richland College
Dallas, TxSkills
- JIRA and Confluence systems
- IKA processing system
- NASCO processing system
- Blue-Square/ITS system
- BlueChip
- PIPP & PAPP pricing system
- Premier pricing system
- CMS - FISS processing system
- Microsoft Word
- PowerPoint
- Microsoft Excel
- Microsoft Office
Certification
- Medical Assistant/Claims Coding Certificate, Concorde College, Dallas, TX
- Six Sigma Training, White & Yellow Belt
Languages
Spanish
Full Professional
Timeline
Lead Claim’s Specialist/Trainer
Dell Services/NTT Data
01.2013 - 05.2024
Lead Quality Assurance Specialist
Dell Services/NTT Data
01.2013 - 07.2021
Claims Unit Lead /Trainer II
Trailblazer Health Enterprises, LLC
10.2006 - 12.2012
Provider Relations Specialist
Blue Cross and Blue Shield of Texas, Inc.
07.1996 - 07.2006
Healthcare Management Associate Degree -
Richland College
High School -
Lubbock High School
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