Karla Del Llano
Sebring,FL
Summary
Enthusiastic Lead Senior Medical Claims Processor proudly offering over 15 years experience in handling both domestic and international claims in a production and quality driven environment.
Overview
17
17
years of professional experience
Work History
Senior Lead Claims Specialist
Payer Fusion
08.2020 - Current
- Reviewed insurance and claims documents to verify required information and secure any missing data for settlements.
- Followed up with customers on unresolved issues.
- Understood requirements for disputes, gathered evidence to support claims and prepared customer cases to handle appeals.
- Monitored compliance with regulations and industry best practices to promote fair and proper treatment for insured customers.
- Responded to inquiries by answering questions, providing information and directing customers to appropriate resources.
- Conducted full claim investigations and reported updates and legal actions.
- Escalated files with significant indemnity exposure to supervisor for further investigation.
- Collaborated with legal counsel to make organizational claims decisions aligning with governing laws.
- Utilized appropriate cost containment techniques to reduce overall claim costs.
- Examined claims forms and other records to determine insurance coverage.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Reviewed and analyzed suspicious and potentially fraudulent insurance claims.
- Resolved complex, severe exposure claims using high service oriented file handling.
- Maintained claims data in CMS systems.
- Collected any and all information from customers to complete claims and legal files.
- Maintained suspicious claims database and prepared reports for supervisors.
- Ordered previous medical information to complete complex claim files.
- Accomplished multiple tasks within established timeframes.
- Cross-trained existing employees to maximize team agility and performance.
- Onboarded new employees with training and new hire documentation.
Claims Specialist
BUPA
12.2009 - 03.2020
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions while adhering to SLAs.
- Knowledge and use of medical terminology, ICD-9, ICD-10 and CPT coding claims for appropriate diagnosis and procedures.
- Met and exceeded minimal production goals while maintaining a QC score above 98%.
- Evaluated CPT codes, ensuring that corresponding ICD 10 codes matched.
- Processed DRG claims and other claims filed using different pricing methods and message codes.
- Handled medical records ensuring that services met medical necessity.
- Handled complaints by adhering to both international and domestic guidelines.
- Identified financial variances and there trends.
- Evaluated BlueCross and BlueShield, UHC, and Olympus (Aetna) claims for both in network and out of network providers.
- Adhered to internal and domestic Service Level Agreements on first pass, adjustments, prompt pay state and others.
- Responded to claim related inquiries via email or telephone including but not limited to coinsurance, deductible and claim handling.
- Assisted in developing recommendations for improvement to the claims processing functions within the department.
- Uploaded documentation and reports to corporate database system using ScanDox to facilitate smooth claims processing.
- Reviewed and answered queries via Sales Force regarding claim status, general inquiries, appeals, denials and plan to plan questions in a timely fashion.
Data Entry Specialist
BUPA
12.2006 - 08.2009
- Sorted, organized, scanned and indexed incoming claims documents to source system.
- Maintained quality levels above prescribed minimums to support team productivity and efficiency.
- Completed accurate and efficient data entry and database updates to support claims operations.
- Identified and corrected data entry errors to prevent duplication across systems.
Education
High School Diploma -
Southwest Miami Senior High School
Miami, FLSkills
- Quality control
- Attention to detail
- Self-motivated
- Excellent communication skills
- Bilingual (English/Spanish)
- HIPAA Procedures
- Fraud Detection
- Diagnostic Codes
- Mentoring New Hires
- Coverage Determination
- Complex Coverage Issues
- Policy and Procedure Explanations
- Claims Investigations
- Productivity Standards
Timeline
Senior Lead Claims Specialist
Payer Fusion
08.2020 - Current
Claims Specialist
BUPA
12.2009 - 03.2020
Data Entry Specialist
BUPA
12.2006 - 08.2009
High School Diploma -
Southwest Miami Senior High School
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