Soarian Financials
LISAMONQUIE Tiburcio
Senior Quality Specialist
Bethlehem,PA
Summary
Experienced in quality management, process optimization, and regulatory compliance. Utilizes analytical skills to identify and resolve issues, ensuring the maintenance of high product standards. Possesses a strong understanding of quality control methodologies and adept at coordinating teams effectively within the medical insurance feild.
Overview
25
25
years of professional experience
2
2
Languages
Work History
Senior Quality Specialist
Independence Blue Cross (IBX)
04.2023 - Current
- Improve product quality by implementing rigorous testing protocols and identifying areas for improvement
- Ensure compliance with industry standards by conducting internal audits and updating documentation as needed
- Reduce customer complaints by addressing root causes and implementing corrective actions in a timely manner
- Educate employees on specific QA standards and confirmed maintenance of standards
- Streamline quality assurance processes for increased efficiency and reduced waste
- Document and execute detailed test plans and test cases and summarized and logged audit findings for reporting purposes
- Record and organize test data for report generation and analysis
- Improved product quality by implementing rigorous testing protocols and identifying areas for improvement.
- Spearheaded root cause analysis efforts on critical non-conformances from both internal audits and external customer feedback leading to swift resolution and prevention of future occurrences.
- Optimized supplier relationships through regular meetings and performance evaluations promoting continuous improvement in their delivery of services.
- Managed cross-functional teams to achieve project goals within tight deadlines, leading to successful product launches.
- Implemented statistical process control methods to monitor production processes, enabling proactive identification of potential issues before they became problems.
- Ensured compliance with industry standards by conducting internal audits and updating documentation as needed.
- Assisted in selecting and validating test platforms needed for effective quality contractual audits, ensuring accurate pricing.
Senior Billing Associate
Holy Family Senior Living, LCC
03.2022 - 04.2023
- Conduct daily reviews of long-term care (LTC) billing and process electronic claims for insurance carriers
- Complete and submit MA 103 and MA 51 forms in compliance with requirements
- Functioned as key point of contact for billing data integrity matters for clients, vendors and various internal departments
- Improved billing accuracy by thoroughly reviewing invoices and cross-referencing data with client accounts
- Maintained updated records of customer account information to ensure accurate and timely billing processes
Member Services Liaison
AblePay Health Saving
11.2019 - 03.2022
- Maintain accounts receivable aged 30–120 days to ensure timely resolution
- Review and adjudicate electronic and paper claims daily
- Enhance customer satisfaction by swiftly addressing concerns and providing solutions to various issues
- Interpret CMS policies and guidelines to optimize reimbursement processes
- Ensure prompt claim processing and payment to providers
- Translate company documents from English to Spanish as needed
- Solved conflicts and addressed issues that occurred between other entities and providers
- Manage non-par provider accounts and verify patient insurance eligibility and benefits
- Prepare and submit appeals for services deemed 'Not Medically Necessary,' including clinical policy bulletin reviews
Hospital Accounts Receivable Manager
Holy Redeemer Health Systems
07.2018 - 11.2019
- Processed incoming payments in accordance with established financial policies
- Analyze AR trends for contract and system issues, providing actionable insights
- Prepare financial reports on contractual adjustments weekly and monthly
- Handle denial reviews and initiate appeals for inpatient and outpatient procedures
- Reconcile daily AR ledger and verified proper posting
- Manage a team of accounts receivable specialists, providing guidance and support for optimal performance
Group Manager
Advanced Reimbursement Solutions
11.2016 - 07.2018
- Ensured compliance with industry regulations and company policies, mitigating risks associated with non-compliance issues
- Conducted competitive analysis administrative and clinical project data to measure efficiency and effectiveness, providing actionable recommendations
- Implemented training programs to improve staff skillsets, enhancing overall productivity and job satisfaction
- Collaborated with other group managers to develop best practices for operational efficiency across departments
Education
Bachelor of Science - Healthcare Administration
University of Phoenix
Tempe, AZHigh School Diploma - undefined
Castro Valley High School
Castro Valley, CASkills
Quality risk assessment
Process validation
Document control
Quality management systems
Software quality assurance
Test method development
Team leadership
Preventive action planning
Quality metrics monitoring
Quality auditing
Problem-solving skills
Customer service
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Work Preference
Work Type
Full TimeLocation Preference
RemoteHybridImportant To Me
Career advancementWork-life balanceFlexible work hoursCompany CulturePersonal development programsHealthcare benefitsWork from home option401k matchSoftware
BI Lauch Pad
Government Payors
Point Click Care
EPIC
CPSI
Assurance / Health Logic
Multiple Clearing House Applications
Highmark Platform
HRP
All Microsoft Office Applications / Outlook
Sales Force
Languages
Spanish
Full Professional
English
Native or Bilingual
Timeline
Senior Quality Specialist
Independence Blue Cross (IBX)
04.2023 - Current
Senior Billing Associate
Holy Family Senior Living, LCC
03.2022 - 04.2023
Member Services Liaison
AblePay Health Saving
11.2019 - 03.2022
Hospital Accounts Receivable Manager
Holy Redeemer Health Systems
07.2018 - 11.2019
Group Manager
Advanced Reimbursement Solutions
11.2016 - 07.2018
High School Diploma - undefined
Castro Valley High School
Bachelor of Science - Healthcare Administration
University of Phoenix