Jennifer M. Alfonso
Opa-locka
Summary
Detail-oriented Claims Examiner ensures accuracy in medical claims processing, adhering to regulations and company standards. Proficient in investigating discrepancies, assessing coding accuracy, and collaborating with providers for timely resolutions, contributing to enhanced efficiency and customer satisfaction.
Overview
22
22
years of professional experience
Work History
Claims Examiner III- Collector
Provider Network Solutions
Doral
10.2022 - Current
- Reviewed and processed medical claims for accuracy and completeness according to established guidelines.
- Analyzed provider contracts to confirm reimbursement levels met established benchmarks.
- Investigated discrepancies in claims data, reconciled errors, and corrected inaccuracies.
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Determined the appropriate payment amount based on contractual agreements with providers.
- Monitored accounts receivable aging reports to ensure timely payments from payers.
- Performed audits of submitted claims to ensure payment calculations adhered to regulatory standards.
- Collaborated with billing, customer service, and IT departments to streamline claim processing and resolve issues.
- Investigated complex cases involving multiple customers or departments.
- Ensured that all resolutions were compliant with relevant regulations.
- Adhered strictly to legal regulations governing privacy, confidentiality, security, and fraud prevention measures.
- Performed regular audits of completed files for compliance with regulatory standards.
Claims Processor Analyst
WebPt Inc
02.2022 - 10.2022
- Investigated and resolved problem claims, adjudicated claims based on eligibility, and confirmed member coverage.
- Ensured compliance with Medicare and Medicaid guidelines in all claims submitted.
- Maintained compliance with Medicare and Medicaid guidelines in all submitted claims.
- Conducted monthly pre-payment audits to ensure adherence to payment standards and compliance protocols.
Reimbursement Specialist
CareMetx
11.2021 - 01.2022
- Processed patient reimbursement claims efficiently and accurately.
- Calling Insurance companies to verify if the Medication was covered through primary or secondary insurance and checking the member responsibility whether through a copayment or co-insurance collecting the information.
- Calling Insurance companies to verify if the Medication was covered through primary orsecondary insurance and checking the member responsibility whether through a copayment orco-insurance collecting the information.
- Reviewed healthcare documentation for compliance with payer requirements.
- Communicated with patients and providers to resolve billing inquiries.
Provider Credentialing
Humana
Miami
08.2014 - 10.2021
- Coordinated credentialing process across multiple healthcare facilities, ensuring compliance and efficiency.
- Verified provider credentials through primary source verification methods.
- Reviewed and updated credentialing policies to align with industry best practices for Medicare, Medicaid, and CAQH applications.
- Evaluated provider applications for compliance with regulatory standards.
- Collaborated with medical staff to address credentialing issues and concerns.
- Managed documentation and maintained accurate records in credentialing databases.
- Facilitated training sessions for new team members on credentialing policies.
- Monitored changes in government regulations pertaining to healthcare provider enrollment and credentialing processes.
- Guided staff members on credentialing requirements and regulations, enhancing team understanding and compliance.
Medical
CSI Caregiver Services Inc
06.2021 - 10.2021
- Coordinated insurance collections for caregiver services to ensure timely payments
- Checking timesheets in/out and billing the correct medical services
- AR reports, EOB follow ups and working accounts based on the AR report buckets
- Insurance Payment posting on accounts.
- Checking timesheets in/out and billing the correctmedical services
Medical Biller/Collector
Continucare Corp/Humana Inc
Miami
08.2011 - 08.2014
- Medical Insurance Collections, Cash receipts payment posting specialist
- AR reports, EOB follow ups, collection calls, Billing and coding medical reports
- Medicaid claim adjuster
- Collected payments from multiple centers and posted to patient accounts, ensuring balanced month-end reconciliation with bank statements.
- Reviewed patient insurance information for accuracy and completeness, facilitating timely claims submission.
- Processed medical claims using advanced billing software systems.
- Maintained up-to-date knowledge of government regulations related to healthcare reimbursement policies and procedures.
- Tracked payments due from insurance companies and third-party payers by generating detailed reports.
- Coordinated with insurance providers to resolve billing discrepancies, improving claim approval rates.
- Managed accounts receivable to ensure timely payments from payers.
- Compiled and processed data for billing purposes utilizing billing software programs.
- Working with the clearing house Gateway EDI
Billing and coding Specialist
Eiber Radiology
Hialeah
12.2007 - 12.2010
- Reviewed and coded medical records for accuracy and compliance with regulations.
- Analyzed coding discrepancies to ensure proper reimbursement for radiology services.
- Collaborated with healthcare providers to clarify documentation and coding requirements.
- Analyzed claims and reviewed status to ensure reimbursements aligned with contract fee schedules
- Posted electronic and manual payments, generated patient statements, and collected copayments and deductibles, managing EOBs effectively
Assistant office manager
Doctors Health Group of South Florida
Plantation
12.2004 - 12.2007
- Oversaw the cardiology, nuclear medicine, and diagnostic department, performed insurance verification, and responded to phone inquiries.
- Check in/ check out
- In charge of the Cardiology, Nuclear Medicine and diagnostic department, Insurance verification and answering phones
- Conducted patient check-in and check-out procedures.
Front desk Receptionist
Waterman Dermatology
Plantation
12.2003 - 12.2004
- Answering phone calls, filing patient charts collecting co-pay scheduling appointments.
- Coordinated communications between patients and medical staff to enhance service delivery.
- Maintained organized patient records using electronic health record systems.
- Answering phone calls, filing patient charts collecting co-payscheduling appointments.
Education
Bachelor’s Degree - healthcare administration
University of Phoenix
Miami, FL01-2017
Billing & Coding Specialist certificate -
National School of Technology
Hialeah, FL01-2006
High School Diploma -
Miami Lakes Tech Educational Center
Miami Lakes, FL01-2005
Skills
- Claims processing
- Claims management
- Claims evaluation
- Claims investigation
- Claims Strategy
- Claims analysis
- Coverage determination
- Payment processing
- Provider enrollment
- Regulatory compliance
- Credentialing compliance
- Healthcare Regulations
- Data Verification
- Database Management
- Microsoft Office Suite
- Microsoft Word, Excel, PowerPoint, Medisoft, Medware, Medstar, Evips
- Revflow
- Team Leadership
- Team Collaboration
- Team training
- Decision making
- Critical Thinking
- Verbal communication
- Public speaking
- Regulatory compliance
- Credentialing compliance
- Regulatory adherence
Languages
- English
- Spanish
References
References: Upon Request
Timeline
Claims Examiner III- Collector
Provider Network Solutions
10.2022 - Current
Claims Processor Analyst
WebPt Inc
02.2022 - 10.2022
Reimbursement Specialist
CareMetx
11.2021 - 01.2022
Medical
CSI Caregiver Services Inc
06.2021 - 10.2021
Provider Credentialing
Humana
08.2014 - 10.2021
Medical Biller/Collector
Continucare Corp/Humana Inc
08.2011 - 08.2014
Billing and coding Specialist
Eiber Radiology
12.2007 - 12.2010
Assistant office manager
Doctors Health Group of South Florida
12.2004 - 12.2007
Front desk Receptionist
Waterman Dermatology
12.2003 - 12.2004
Bachelor’s Degree - healthcare administration
University of Phoenix
Billing & Coding Specialist certificate -
National School of Technology
High School Diploma -
Miami Lakes Tech Educational Center