Summary
Overview
Work History
Education
Skills
Languages
Timeline
Generic

KARIME CIFUENTES

Canyon Country,Ca

Summary

Knowledgeable and dedicated customer service professional with over a decade of experience in the Collections & Appeals sector, specializing in healthcare finance and insurance claims. In my role as a Claims Specialist, I effectively manage and process all assigned claims, ensuring accuracy and timely case resolutions which contribute significantly to the optimization of the revenue cycle. My background includes significant experience in managing appeals and denials, where I built strong client relationships and maintained high customer satisfaction by providing outstanding service and executing proficient claims practices. My skills include detailed documentation review, accurate claim amount calculations, and knowledge of insurance contracts, enhanced by a CCS Coding Certificate currently in progress. With a proven track record in improving service delivery through effective claims handling and appeals management. I am poised to continue making impactful contributions to company success.

Overview

22
22
years of professional experience

Work History

Claims Specialist

Henry Mayo Newhall Hospital
03.2020 - Current
  • Handled all assigned claims promptly and effectively
  • Ran all claim reports through company system
  • Determined proper policy coverages and applied appropriate claims practices to reach case resolution
  • Escalated all claims to necessary departments and reviewed all claims documents for accuracy
  • Acted as liaison in reference to all severe incident reports, reinsurance reports and all other case needs
  • Built long lasting client relationships and prioritized outstanding customer service

Appeal & Denial Specialist

Good Samaritan Hospital
05.2015 - 03.2020
  • Timely response to insurance request
  • Reported claims to insurance companies and gathered the adjuster information and claim number
  • Kept accurate record of claim recoveries in the company system
  • Generated all Claims acknowledgment documents
  • Submit written appeals for claim denial and underpayments

Insurance Claims Representative

Good Samaritan Hospital
03.2012 - 05.2015
  • Delivered quality customer service to assigned, insured and claimants throughout entire claims lifecycle to promote service times
  • Negotiated settlements for uncomplicated claims in accordance with actual company liability
  • Determined liability, compensability and benefits due on each claim
  • Updated account demographic information as needed

Charge Entry Specialist

Good Samaritan Hospital
10.2002 - 01.2012
  • Update the hospital Charge Master and Order Entry systems
  • This includes requests for placing accounts on hold and inactivating charge codes and maintaining the link between CDM and Order Entry System
  • Document payment recoveries from audit results and payer reimbursement issues

Education

Medical Billing & Coding -

American Career College
12.1999

General Studies -

East Los Angeles College
06.1998

Diploma -

Huntington Park High School
06.1993

Skills

  • Documentation Review
  • Insurance contract rates and terms
  • CCS Eligilbe- Certified Coding Specialist & AHIMA
  • Data Entry
  • Verbal and Written Communication
  • Claim Amount Calculations
  • New Policies Processing
  • Eligibility Determination
  • Coverage Determination
  • Customer Service
  • Microsoft office
  • Data Analysis
  • Revenue Cycle
  • Medi-Tech
  • Microsoft Word
  • Microsoft Excel

Languages

Spanish
Full Professional

Timeline

Claims Specialist

Henry Mayo Newhall Hospital
03.2020 - Current

Appeal & Denial Specialist

Good Samaritan Hospital
05.2015 - 03.2020

Insurance Claims Representative

Good Samaritan Hospital
03.2012 - 05.2015

Charge Entry Specialist

Good Samaritan Hospital
10.2002 - 01.2012

General Studies -

East Los Angeles College

Diploma -

Huntington Park High School

Medical Billing & Coding -

American Career College
KARIME CIFUENTES