Summary
Overview
Work History
Education
Skills
Timeline
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Kelli Mendoza-Blas

Roseville,CA

Summary

Results oriented and dedicated professional with 20+ years of learning experience in healthcare and administrative skills, Hardworking , dependable, limitless tenacity and eager to explore new challenges; capable of handling heavy workloads with efficiency and accuracy; works well with others and independently; positive attitude; dedicated and devoted in exceeding expectations.

Overview

23
23
years of professional experience

Work History

Claims Auditor

Centene/Health Net
11.2015 - 12.2023
  • Audits and validates routine pre/post pay claims to determine correct adjudication as well as compliance with corporate polices and procedures.
  • Audit's provider data loaded into the claims processing systems; documents and reports audit results; research claims and enrollment discrepancies as they are related to provider data.
  • Research issues from claims reviewed to determine origin for feedback, and distribution to management.
  • Performs routine and complex audits on medical review claims to identify expectations to established claims adjudication requirement.
  • Paricapets in communications with claims department regarding results of claims audited and / or reviewed , to inprove claims processing and resolutions.
  • Maitains current working knowledge of Health products, polices and procedures, contract, and benefit plan coding as well as health insurance industry and regulatory and certificationc standards.

Claims Examiner

Centene/ Health Net
10.2005 - 11.2015
  • Identify authorization issues and trends , research for potential configuration related work process changes.
  • Research verbal and written providers claims inquiries as needed.
  • Process claims billed on UB92, CMS1500, And member claims.
  • Lines of business HMO, PPO, POS, MEDI-CAL
  • Researched and resolve issues relating to billed CPT codes and ICD-9 codes .

Provider Appeals

Health Net
12.2002 - 09.2005
  • Gather, analyze and report verbal and written provider appeals.
  • Prepare response letters for provider complaints.
  • Maintain files on individual appeals.
  • Manage large volume of documents including copying, faxing and scanning incoming mail.
  • Coordinate with Medical Director(s) to clarify medical determination or clinical rationale.

Provider Services Representative

Health Net
07.2000 - 11.2002
  • Answered escalated and complex inquires from providers regarding claims, eligibility, covered benefits and authorizations status matters.
  • Educate providers on health plan initiatives.
  • Provide first call resolution working with appropriate internal / external resources and insure closure of all inquires.
  • Research and identify processing inaccuracies in claim payments and route to the appropriate team for claim adjustments.
  • Maintain performance and quality standards based on established call center metrics including turn-around times.

Education

GED -

Vista Nueva High School
Sacramento, CA
06.1982

Skills

  • Claims Auditing
  • Compliance and Regulations
  • Exemplary Communication Skills
  • Critical thinking
  • Interpersonal skills
  • Documentation review
  • Problem solving
  • Claims processing
  • Insurance knowledge

Timeline

Claims Auditor

Centene/Health Net
11.2015 - 12.2023

Claims Examiner

Centene/ Health Net
10.2005 - 11.2015

Provider Appeals

Health Net
12.2002 - 09.2005

Provider Services Representative

Health Net
07.2000 - 11.2002

GED -

Vista Nueva High School

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Kelli Mendoza-Blas