Maria R Navarro
Rialto,CA
Summary
Medical Claims Processing Supervisor with extensive expertise in overseeing claims department operations and ensuring regulatory compliance in managed care environments. With over 23 years of industry experience, I excel in optimizing workflows, resolving provider disputes, and collaborating on health plan audits. Proficient in utilizing systems like EZ-Cap and Epic System, I am committed to enhancing operational efficiency and fostering a collaborative team environment.
Overview
23
23
years of professional experience
Work History
Claims Processing Department - Supervisor
EPIC Management a part of Optum-Ca/ UHG
Redlands, CA
10.2017 - 05.2025
- Oversee daily operations of claims department workflow for EPIC affiliate medical groups
- Supervised examiners and claims-processing staff.
- Directs the daily claims operational functions with other claims supervisors to provide consistency between institutional and HMO group claims.
- Address provider disputes in detailed-level claims issues related to claims adjudication.
- Managed the pended claims report to ensure timely resolution in the claims check run process.
- Evaluate and oversee the timely processing of all claims using system generated reports.
- Collaborated with the claims compliance supervisor to primarily prepare all health plan audits, with review of information as required.
- Review the regularly scheduled claim check run to ensure accuracy and completeness on a consistent basis.
- Managed a consistent workflow by validating that the claims are being processed according to the Health Plan Division of Financial Responsibility when reviewing daily processing claims, issues, and errors.
- Delivered documentation to Director of Claims addressing claims errors to facilitate development of corrective action plan for claim examiners and processors.
- Engaged in weekly meetings with senior leadership teams to review progress
- Evaluate and direct updates of all systems aiding examiners in effectively adjudicating claims (DRG, APC, ASC, Medicare Pricer, Virtual Auth).
- Participate in meetings with EDI team leadership regarding functions of electronic claims and operational matters
Utilization Management Department
Epic Management LP
Redlands, CA
04.2015 - 10.2017
- Verified insurance coverage, benefits and processed prior authorizations/ Pre-Certification.
- Collaborated with UM case managers to facilitate timely discharge planning and transition of care.
- Monitored patient admissions and discharges to optimize care coordination and resource utilization.
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
- Coordinated discharge planning to ensure continuity of care post-hospitalization for patient needs.
- Monitored compliance with regulatory requirements related to utilization management activities.
- Maintained up-to-date knowledge of industry regulations affecting utilization management practices.
PCP Referrals/ Pre-service Authorization
Family Practice Medical Group of San Bernardino
San Bernardino, CA
02.2012 - 03.2015
- Facilitated the processing and referrals/auths from providers, hospitals, and nursing facilities, ensuring timely patient access to services.
- Managed daily processing of primary care physician referrals and authorizations.
- Managed multiple tasks efficiently to support utilization management and authorization/referral operations.
- Notify the Group's Medical Director and Nurse Case Managers of hospital admissions and discharges.
- Ensured confidentiality of patient files in accordance with HIPAA regulations.
- Scanned and uploaded essential documents into the system upon patient admission and discharge, maintaining compliance and accuracy.
- Verify insurance eligibility and benefits.
Medical Claims Examiner/ Claims Processor
Family Practice Medical Group of San Bernardino
San Bernardino, CA
08.2009 - 02.2012
- Manage medical professional claims and execute data entry into the system.
- Coordinate the opening, sorting, and counting of Daily Mail receipts.
- data entry of daily mail received into the tracking database.
- Responsible for coordinating with the claims compliance and regulatory data analysts to retrieve all health plan audit information and manage the assembly of the documentation.
- Provide contract interpretation information to forward claims to the appropriate payer in a timely manner.
- Manage the provider dispute and appeal process to ensure proper routing.
- Review and manage the double-date stamp claims process to ensure routing and data entry are correct.
- Analyze the health plan DOFR to make a sound decision on payment responsibility.
- Manage health plan for misdirected mail returns while adhering to industry guidelines
- Collaborated with internal departments such as Provider Relations, Medical Management, and Quality Assurance, as needed.
- Processed appeals from denied claims according to established procedures while ensuring compliance with applicable laws and regulations.
- Attend claims operational meeting and participate in the dialog to provide insight and assists in bringing resolution to open matters.
Claims Examiner and Customer Service Rep
Chino Medical Group
Chino, CA
09.2004 - 06.2009
- Processed HCFA 1500 claim form and UB-92, and adjudicated complex medical claims efficiently.
- Performed data entry into the computer system to record information regarding claim status.
- Managed workloads efficiently by prioritizing tasks based on urgency or importance.
- Provided excellent customer service, resolving claim concerns, and queries promptly.
- Addressed patient concerns with empathy and professionalism.
- Preparation of health plan audits.
- Developed a detailed understanding of the company's policies and procedures related to claim processing and payment determination.
- Provided guidance to other staff members regarding claim processing rules and regulations.
Medical Records
Chino Medical Group
Chino, CA
04.2004 - 09.2004
- Executed timely delivery of patient charts to PCP workstation, enhancing preparation for upcoming patient appointments.
- Answered phone inquiries from patients regarding their medical records.
- Coordinated medical records requests from physicians and hospitals.
- Maintained patient medical records, ensuring accuracy and confidentiality.
- Ensured accuracy of medical records in compliance with HIPAA regulations and standards.
- Maintained filing systems for patient medical records, correspondence, reports, forms.
- Assisted with referrals and prepared medical records for patients.
Dental Billing Specialist
Dr. Surinder Sharma
Upland, California
12.2001 - 05.2002
- Processed dental insurance claims accurately and efficiently.
- Communicated with patients regarding billing inquiries and payment options.
- Coordinated with dental staff to ensure accurate coding of services.
- Resolved billing discrepancies with insurance companies in a timely manner.
- Verified patient insurance eligibility and coverage details.
- Complied with HIPAA regulations while handling confidential patient information in accordance with company policies.
- Provided monthly analysis of accounts receivable aging report to management team.
Education
Diploma - Medical Insurance Billing And Coding
Bryman College
CA06-2021
High School Diploma -
Upland High School
CA06-1996
Skills
- Health Access, EZ-Cap, Epic System/Hyperspace
- Provider disputes, appeals, and claim adjustments
- CMS, DMHC, and DHCS rules and regulations
- ICD-9 & ICD-10, RBRVS, HCPCS and CPT
- Ability to multitask efficiently, thoroughly, and in a prioritized manner; to work quickly, accurately, and independently; and to anticipate needs and solve problems
- Systems and software expertise
- Workplace safety
- Provider Relations
- Critical thinking
- Verbal and written communication
- Shared risk and full risk claims
- Team leadership
- Regulatory compliance
- Claims processing, adjudication
- Medical terminology and coding
- HMO claims in a managed care environment
References
References available upon request.
Timeline
Claims Processing Department - Supervisor
EPIC Management a part of Optum-Ca/ UHG
10.2017 - 05.2025
Utilization Management Department
Epic Management LP
04.2015 - 10.2017
PCP Referrals/ Pre-service Authorization
Family Practice Medical Group of San Bernardino
02.2012 - 03.2015
Medical Claims Examiner/ Claims Processor
Family Practice Medical Group of San Bernardino
08.2009 - 02.2012
Claims Examiner and Customer Service Rep
Chino Medical Group
09.2004 - 06.2009
Medical Records
Chino Medical Group
04.2004 - 09.2004
Dental Billing Specialist
Dr. Surinder Sharma
12.2001 - 05.2002
Diploma - Medical Insurance Billing And Coding
Bryman College
High School Diploma -
Upland High School
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