Karina Felix

• Assisted individuals in evaluating health plan choices, focusing on optimal selections tailored to unique health needs.
• Provided detailed responses to inquiries regarding coverage costs and benefits, ensuring clarity and comprehension.
• Investigated and resolved billing and claims discrepancies, fostering clear communication and member satisfaction.
• Investigated and rectified billing discrepancies and claims challenges for members, facilitating efficient resolution processes.
• Engaged collaboratively with team to drive goal achievement and maintain high standards of customer service.
• Achieved high customer satisfaction by efficiently managing about 30 daily inquiries through calls, emails, and faxes. Enhanced communication efficiency by addressing approximately 30 customer interactions daily through various channels. Optimized customer engagement by processing around 30 inquiries each day through effective management of calls, emails, and faxes.
• Analyzed data trends to identify improvement opportunities in care delivery processes.

• Analyzed coding practices to uncover billing errors, resulting in improved claim approval rates and financial recovery.
• Evaluated medical records for motor vehicle accident claims, verifying coding accuracy and establishing medical necessity to facilitate timely payment submissions.
• Conducted thorough validation of code assignments and claims to guarantee adherence to payment processing standards.
• Performed detailed audits to uncover coding discrepancies, safeguarding reimbursement accuracy.
• Analyzed coding variances through provider consultations, guaranteeing compliance with national correct coding initiative (NCCI) regulations.
• Supported coding team with complex claim resolution involving multi-procedure audits and modifier application
• Audited 100+ claims daily while maintaining 99% accuracy rate
• Analyzed audit data to identify coding trends, flagged high-risk claims, and collaborated with providers to resolve complex billing discrepancies
• Reviewed medical records, police reports, witness statements, and other information to assess damages
• Attended continuing education classes to keep up with changing laws and rules
• Managed multiple tasks and met strict deadlines
• Made inbound and outbound calls to providers and insured people
• Worked with other departments such as Underwriting and Risk Management
• Used Microsoft Office and industry software programs
• Led coding audits that identified billing errors, recovering thousands in overpayments and significantly reducing claim denials
• Used knowledge of current Current Procedural Terminology (CPT) codes, HCPCS, Modifiers, and ICD-10 codes
• Analyzed audit data to identify coding trends and flagged high-risk claims, collaborating with providers to resolve complex billing discrepancies

• Resolved pharmacy billing discrepancies by verifying insurance coverage and correcting claim submission errors, ensuring accurate billing for patients.
• Resolved pharmacy billing differences by verifying insurance coverage and correcting claim submission errors
• Assisted customers with billing inquiries and promptly addressed their concerns, contributing to high satisfaction ratings.
• Verified accuracy of accounts payable payments, resulting in 100% reduction in payment errors and check reissues.

Healthcare Compliance, HIPAA Privacy & Security, Risk Management, Medical Law & Ethics

• Graduated with Honors
• GPA: 3.8/4.0