MARGARITA LITTNER
San Dimas
Summary
Experienced with claims resolution, risk assessment, and team leadership. Utilizes strategic planning to streamline operations and mitigate risks. Track record of fostering collaborative environments and driving results.
Overview
57
57
years of professional experience
Work History
Claims Director
PIH HEALTH/HEALTHMED SERVICES
01.2017 - Current
- Direct all claims processing operations for the enterprise’s hospital/medical group/ancillary care Integrated Delivery System. This includes Claims, Audit, Compliance, Enrollment, Capitation, Revenue Recovery and Customer Service.
- Increased auto-adjudication rules to maximize the claims system’s automation capabilities to 87%.
- Provide excellent Customer Service to physicians, ancillary providers and health plan enrollees.
- Recovered over 1.5 million dollars in overpayments made the four years I was with Memorial Care.
- Absorbing new growth in membership from 42,000 lives to 90,000 lives, due to three new clients for the MSO, in a span of 18 months.
- Consulted and assisted Hoag Health System in their IPA startup with implementation of a claims department, from processing claims, training manual, configuration, eligibility loads and including performing their pre-delegation audits with the health plans they had contracted.
- Maintain annual delegated status with all health plans.
Shared-Risk Claims Manager
MEMORIAL CARE/ NAUTILUS HEALTHCARE MGT GRP
01.2013 - 01.2017
- Restructured a claims staff of 55 to increase efficiency in customer service, claims operations and revenue recovery.
- Transitioned EZ-CAP claims system to Tapestry/Epic within a six-month period while maintaining claims timeliness and accuracy.
- Resolved the department’s three-year history of noncompliance on claims accuracy by auditing and correcting the system’s fee schedule and health plan benefit in loads.
- Successfully integrated three claims departments, Memorial Care Med Grp, Nautilus Healthcare Management Grp and Capitation Services.
Claims Director
PIH HEALTH PHYSICIANS
01.2005 - 01.2013
- Directed all claims processing operations for the enterprise’s hospital/medical group/ancillary care Integrated Delivery System.
- Provided excellent Customer Service to physicians, ancillary providers and health plan enrollees.
- Developed and implemented a Revenue Recovery Unit for insured services, claims overpayments, COB, ESRD and TPL, which recovers approximately $1 million dollars annually.
- Integrated two claims departments during the merger between Presbyterian Health Physicians and Bright Medical Associates with a combined total of 68,000 capitated lives.
- Wrote claims processing rules in order to maximize the claims system’s automation capabilities.
Compliance and Audit Manager/HIPAA Privacy Official/Compliance Manager
ARCADIAN MANAGEMENT SERVICES
01.2002 - 01.2005
- Managed a staff of 8 auditors and one Supervisor, 20 remote processors, 3 compliance coordinators, 4 Customer Service Reps and one Supervisor and 2 clerks to successfully administer claims functions for 13 IPAs. All 13 IPAs were maintained on annual delegated status.
- Designated as HIPAA Privacy Official for achieving HIPAA Privacy Rule compliance ahead of schedule; saved several thousand dollars in outside consulting fees.
- Headed committee for HIPAA Privacy Rule compliance; oversaw development and implementation of policies, procedures and business associates' contracts.
- Conducted comprehensive research of industry history, ICE interpretations and regulations.
- Designed training program and support materials for employees company-wide; administered ongoing guidance and expertise to all departments.
Supervisor of Quality Control and Compliance
PHYSICIAN ASSOCIATES OF THE GREATER SAN GABRIEL VALLEY
01.2000 - 01.2001
- Increased accuracy of claims payments by developing and implementing procedures and policies; improved overall efficiency of auditing department.
- Identified potential high cost overpayments by conducting in-depth audits and revamping auditing processes.
- Ensured compliance with timeliness requirements of CMS, DHS, DMHC and ERISA by creating a procedure for daily urgent system sweeps to detect claims expiring from compliance and designing daily claims aged inventory report.
Quality Control Lead and Trainer
HUNTINGTON PROVIDER GROUP
01.1992 - 01.1999
- Maximized efficiency and resolved issues by holding weekly meetings with management on quality improvement processes and implementation of procedures.
- Played key role in ensuring successful health plan audits by serving on HCFA compliance task force and participating in corrective action plan during challenging transitional period.
- Developed monthly quality and production reports for claims department and trended errors.
- Slashed claims' backlog and ensured timely processing by supervising temporary staff of 18 claims examiners during peak period.
- Trained new employees in claims processing and core department procedures and policies.
- Integrated daily activities of audit department.
Account Coordinator
METROPOLITAN LIFE
01.1973 - 01.1977
- Held meetings with policy holders to review and discuss policy issues including provisions, modifications, additions and service; acted as intermediary between policy holders and company.
- Provided service to client base with over $1 million in annual premiums.
- Verified renewal rates by analyzing data furnished by actuarial department.
- Developed monthly, quarterly and annual financial reports.
Field Auditor/Claims Examiner
TRANSAMERICA CORPORATION
01.1968 - 01.1973
- Performed field audits on medical, dental and vision claims for self-administered companies.
- Conducted on-site claim examiner audits on weekly disability, medical, dental and vision claims.
Education
Business Administration
EAST LOS ANGELES COLLEGE
Monterey Park, CA01.1970
Skills
- Strategic claims management
- Policy development and implementation
- Understanding of HIPAA and ERISA regulations
- Experienced in leading teams to fulfill mission objectives
- Technically proficient in Microsoft Office software, EZ-CAP, EPIC/Tapestry, MDX and Monument Xpress/Health Trio applications
- Team development and engagement
- Skilled in conveying information effectively
- Confident decision-making
- Advanced Spanish communication skills
- Claims management proficiency
Languages
Spanish
Native or Bilingual
Timeline
Claims Director
PIH HEALTH/HEALTHMED SERVICES
01.2017 - Current
Shared-Risk Claims Manager
MEMORIAL CARE/ NAUTILUS HEALTHCARE MGT GRP
01.2013 - 01.2017
Claims Director
PIH HEALTH PHYSICIANS
01.2005 - 01.2013
Compliance and Audit Manager/HIPAA Privacy Official/Compliance Manager
ARCADIAN MANAGEMENT SERVICES
01.2002 - 01.2005
Supervisor of Quality Control and Compliance
PHYSICIAN ASSOCIATES OF THE GREATER SAN GABRIEL VALLEY
01.2000 - 01.2001
Quality Control Lead and Trainer
HUNTINGTON PROVIDER GROUP
01.1992 - 01.1999
Account Coordinator
METROPOLITAN LIFE
01.1973 - 01.1977
Business Administration
EAST LOS ANGELES COLLEGE
Field Auditor/Claims Examiner
TRANSAMERICA CORPORATION
01.1968 - 01.1973
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