Esmeralda Valadez
San Antonio
Summary
Detail-oriented medical billing professional with over 13 years of experience in processing and resolving insurance claims. Proven track record in improving accuracy and compliance while communicating effectively with providers and members in fast-paced environments.
Overview
20
20
years of professional experience
Work History
Claims Examiner
Health Texas Medical Group
05.2025 - Current
- Processed Medicare Dual and hospital claims, ensuring compliance with regulations and accuracy in claims management.
- Identified claims requiring authorization and conducted research for approval, facilitating efficient processing by authorization department.
- Denied claims accurately and dispatched denial letters, ensuring clear communication of outcomes to providers and members.
- Prepared and dispatched denial letters to providers and members, maintaining clear communication on claim outcomes.
- Researched claims history to identify duplicates for denial, improving accuracy in claims management.
- Answer inbound calls from providers and members for claim inquiry.
Billing Specialist
Health Texas Medical Group
01.2025 - 05.2025
- Processed claims per Cigna, Humana Military, and Tricare for Life policies, ensuring accurate claim processing and correct patient balances.
- Resolved claim issues and addressed denial of reconsideration by contacting insurance companies.
- Prepared and submitted claims appeals to insurance companies, facilitating reimbursement processes.
- Process claims for special projects such as Insurance Rejections, and 2025 Illumed.
- Answer inbound calls and assist with taking payments, making payment arrangements, disputing statements, updating patients’ insurance and account inquiries from patients and clinics.
- Make outbound calls to patients for missing insurance information.
- Reported daily metrics to management, offering insights for performance tracking and decision-making.
Texas Works Advisor
Texas Health and Human Commission
11.2023 - 01.2025
- Interviewed applicants and recipients in person or by phone to gather essential information for financial eligibility determinations for public assistance programs.
- Employed fact-finding techniques to obtain, relate, and evaluate applicant information for accurate eligibility assessments.
- Processed applications in compliance with state and federal regulations and established procedures, guidelines, and timeframes.
- Evaluate data from multiple electronic and other sources to ensure accurate entry into a computer-based eligibility system.
- Compute and authorize benefits based on eligibility determinations.
- Read, understand, apply, and explain detailed regulations and policies.
- Executed basic arithmetic operations to ensure accurate calculations.
Billing Specialist
Pathology Reference Laboratory
08.2022 - 11.2023
- Managed billing for 3 of 4 facilities, ensuring timely processing and accuracy of payments.
- Processed insurance reimbursement claims efficiently.
- Resolved billing and payment issues, increasing customer satisfaction and maintaining account accuracy.
- Ensured accuracy of account balances prior to statements being produced.
- Recorded account charges, payments, and necessary adjustments accurately.
- Investigated and addressed refund requests from insurances, streamlining reimbursement workflows.
- Analyzed remittance codes from Explanation of Benefits and Accounts Receivable Statements.
- Prepared detailed spending and revenue reports for financial analysis.
- Served as a liaison to facilitate communication between insurers and policyholders.
Claims Examiner
WebTPA
06.2016 - 08.2022
- Managed daily claims queue to ensure timely processing within policy timeframes.
- Researched insurance policies to ensure accurate claims processing and compliance.
- Ensured proper eligibility of charges was processed for accuracy and validity.
- Verified provider referrals and insurance authorizations for accuracy.
- Processed account claims and reconciliations, ensuring financial accuracy and minimizing discrepancies.
- Assisted medical professionals and billing management to determine billing and documentation policies.
- Cross-trained in various areas including Tribal, self-funded, retiree, and voluntary insurance products.
- Trained new employees on specific job functions and responsibilities.
- Supported management with report generation, training, and guidance for new employees to enhance onboarding experience.
Customer Service Rep
WebTPA
06.2012 - 06.2016
- Handle inbound calls from clients, providers, and other insurance carriers.
- Researched insurance policies to educate callers on benefits, facilitating smoother claim processing.
- Send claims back to examiners for review due to policy language/client appeals.
- Verified provider referrals and insurance authorizations to ensure compliance with policy guidelines.
- Collaborated with medical professionals and billing management to clarify billing and documentation policies, enhancing compliance and understanding.
- Explained benefits language in accordance with policy guidelines to ensure caller comprehension.
- Make outbound calls to providers to assist client with billing statement from provider.
Customer Service Rep/Claims Examiner
UHC
12.2010 - 06.2012
- Analyzed insurance policies to ensure accurate claims processing.
- Ensured eligibility of charges processed for accuracy and validity.
- Verified provider referrals/ and insurance Authorizations.
- Corrected claims processed against policy language to align with regulations.
- Executed and reconciled account claims to uphold financial accuracy.
- Managed daily claims department functions including coding, charge entry, and posting.
- Supported medical professionals and billing management in determining billing and documentation policies.
Account Manager
UPS
08.2006 - 12.2010
- Coordinated strategies with team members to align sales initiatives and identify new opportunities.
- Provide compelling value proposals to potential and existing customers.
- Maintained knowledge of UPS products and services to develop sales solutions.
- Educated customers on UPS service channels to enhance problem resolution speed.
- Evaluated customer shipping methods to identify improvement areas and introduced tailored UPS shipping solutions.
- Determine customer discounts and write new contracts.
- Reviews customer shipping practices to ensure contractual compliance.
- Worked driver leads to garner new business.
Education
BBA - Business Administration
Our Lady of The Lake University
San Antonio, Texas05-2005
AA - Business Administration
Northwest Vista College
San Antonio, Texas05-2003
Skills
- Insurance Claims
- Claims processing
- Claims documentation
- Claims research
- Claims analysis
- Policy interpretation
- Policy analysis
- Medical Billing
- Team collaboration
- Data verification
- Healthcare procedures
- Microsoft Office
- Customer Service
- Problem solving
- Team collaboration
- Policy analysis
- Claims documentation
Timeline
Claims Examiner
Health Texas Medical Group
05.2025 - Current
Billing Specialist
Health Texas Medical Group
01.2025 - 05.2025
Texas Works Advisor
Texas Health and Human Commission
11.2023 - 01.2025
Billing Specialist
Pathology Reference Laboratory
08.2022 - 11.2023
Claims Examiner
WebTPA
06.2016 - 08.2022
Customer Service Rep
WebTPA
06.2012 - 06.2016
Customer Service Rep/Claims Examiner
UHC
12.2010 - 06.2012
Account Manager
UPS
08.2006 - 12.2010
BBA - Business Administration
Our Lady of The Lake University
AA - Business Administration
Northwest Vista College