Maria T. Delgado
Taft,TX
Summary
Forward-thinking team trainer skilled at working with departments to efficiently meet goals. Successful training analyst according to job title for maximum performance. Proactive and hardworking individual focused on continuous operational improvement.
Overview
27
27
years of professional experience
1
1
Certification
Work History
Claims Operational Coordinator
Driscoll Health Plan
06.2023 - Current
- Develops, implements, and delivers all departmental training curriculum to ensure consistency, efficiency, and quality outcomes in claims department functions; including but not limited to claim support, claims processing, claims adjustments, refund processing, claim appeals, provider claim resolution, and provider claim analysis
- Delivers training to new hires, as well as experienced staff
- Collaborates with departmental leadership and SMEs in training initiatives related to process improvement
- Remains current in understanding and knowledge of all department workflows and processes
- Delivers training in the most appropriate format, including virtually, in a classroom setting, and directly with individuals
- Develops training outlines, timelines, materials, and knowledge tests for all department training initiatives
- Evaluates trainee performance and provides appropriate feedback to departmental leadership
- Maintains positive, consistent communication with Claims staff
- Maintains accurate training records
- Utilizes appropriate training and motivational techniques to help staff achieve peak performance
- Maintains a positive attitude, composure, and flexibility under pressure
Claims Supervisor
Driscoll Health Plan
04.2018 - 05.2023
- Responsible for the daily oversight of the Coordination of Benefits team, to include productivity, quality, training and coaching of staff
- The position responsibilities include inventory management, ensuring adherence with operational policies and procedures, ensuring correct handling of claims involving other insurance coverage, as well as continual process improvement
- The position also provides technical and professional leadership to the department and serves as a subject matter expert to internal and external business partners, regarding COB related policies and procedures
- Develop and maintain an environment that encourages teamwork and communication and supports quality and process improvement suggestions and solutions
- Demonstrate business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines
Claims Supervisor
Valence Health
01.2015 - 03.2018
- Manage monthly production and quality stats for claim staff of 27 adjudicators, including correspondence analysis as it relates to employee errors
- Coach and counsel staff members as needed
- In conjunction with the claim manager, interview, hire, train and review all claim personnel
- Supervise, motivate, monitor, and mentor the examiners to ensure compliance with claims procedures and standards
- Maintain a working knowledge of the duties of the personnel in the unit
- Manager performance evaluations, status changes, and disciplinary forms as needed
- Analyze workflow reports and procedures to maximize productivity
- Determine the need for assistance from other units when necessary, and aid other units
- Work with claim manager to determine overtime as needed to maintain service standards
- Advise the claim manager about any workflow problems or improvement opportunities both within the claims area and in other operational units
Claims Adjudicator Level II & Level III
Valence Health
09.2014 - 01.2015
- Experienced level adjudicator providing analytical ability to review claim rules and workflows
- Responsible for adjudicating claims to maintain/comply with Service Level Agreements
- Determine accurate payment criteria for clearing pending claims based on defined Policy and Procedures
- Ability to understand logic of standard medical coding (i.e
- CPT, ICD-10, HCPCS, etc.)
- Research CMS1500 claim edits to determine appropriate benefit application utilizing established criteria
- Ability to resolve claims that require adjustments and adjustment projects
- Identify claim(s) with inaccurate data or claims that require review by appropriate team members
- Maintain productivity goals, quality standards and aging timeframes
- Contribute positively as a team player
- Complete special projects as assigned and comply with all departmental and company Policy and Procedures
Medicaid Customer Service Team Lead
Valence Health
08.2011 - 09.2014
- Customer Service Representative: Job to answer all calls within the first 30 seconds
- I was promoted to Medicaid Team Lead within the first 1 1/2 months of being with Valence
- Answer phones, assist CSR'S with claims issues, issuing of ID cards for members, doing updates of PCP'S for members
- Entering of OCI'S for all MCD health plans to resolve claims issues and following up with providers once this is complete
- Responsible for the Sendero Map daily and monthly call statistics and reporting findings to my supervisors
- Posting of all daily statistics to SharePoint for Sendero Health Plan to be able to review their statistics
- Responsible for the daily lunch schedule to ensure we have proper phone coverage for each of the lunch shifts
- I am 1 of 3 SME'S with training on Navitus (Pharmacy) System, to look and see why members are not able to obtain their medications and work with the pharmacy to resolve the issue
- I handle the Sendero Chip/Star check log and responsible for sending it weekly to our Finance Department to resolve issues on checks not received by providers
- Update the CSR tools with the most current information by the Health Plan to ensure CSR'S have the correct and current information available
- Assist in training of new CSR'S to our Department and making sure they have the appropriate materials needed to perform their duties
- Assist my supervisors on handling escalated issues in our department and any other duties as assigned
Intake Coordinator/Insurance & Authorization Specialist
Interim HealthCare
10.2009 - 08.2011
- Receive referrals from Liaisons and enter patient demographic information and status updates in the Patient Data Base; assign new admissions to appropriate nurse for admission
- Verifying all patient insurance benefits, calling and obtaining authorizations on all referrals requiring our services
- Also responsible for the up keep of all authorizations for current patients on Census with our agency
- Coordinate and setup patients with our contract Therapies companies and maintain their authorizations for services
Intake Coordinator
Christus Home Care-Spohn
10.2005 - 10.2009
- Schedule visits for all inquiry and referral callers; dispatch referrals to liaisons, program reps and admission nurses; communicate prospective patient updates to appropriate referral sources
- Facilitate equipment and other admission orders as needed; Enter prospective and admitted patient demographic information and status updates in the patient data base
- Facilitate processing of admission documents from referral call through transfer to appropriate care team; ordering of all DME for patient care needs; ordering of all office and medical supplies
Medical Office Coordinator
Christus Spohn PT & Rehab
09.2001 - 10.2005
- Facilitate all incoming referrals and assign to appropriate discipline for admission; verify insurance coverage and obtain authorization for visits
- Input patient data in to database; Responsible for ensuring the daily operations are organized and accurate, and the workflow is maintained in a current status
- Enter daily patient charges and report daily totals to Business Office Manager; ordering of all office supplies; assist with Medical Records maintenance
- Faxing of orders to obtain MD signatures for approval of Therapy frequencies; provide daily patient charge logs to contracting facilities
Receptionist/ Billing Clerk
Spohn Home Care
09.1997 - 09.2001
- Responsible for working the PBX phone system and direct all incoming calls to appropriate staff
- Printing and faxing/mailing all MD Orders and POC’s for MD signatures; responsible for ordering of medical /office supplies
- Enter patient information in database; assist with the maintenance of medical records; doing chart audits for proper billing submission; filing and performs other duties as assigned
Education
Southern Careers Institute -
Southern Careers Institute
Corpus Christi, TX06.1993
Church’s Management School -
Church’s Management School
San Antonio, TX08.1986
Taft High School -
Taft High School
Taft, TX05.1983
Skills
- Microsoft Word
- Excel
- Epic / Tapestry
- SharePoint
- Data Entry
- Customer Service
- Medical Office Procedures
- Appointment Scheduling
- Insurance Verifications
- Staff Training
- Medical Terminology
- ICD 9 & 10 Coding
- Purchasing of Medical Supplies
- Purchasing Office Supplies
- Auditing of Medical Records
- Team Training
- Customer Relations
- Problem-Solving
- Time Management
- Attention to Detail
- Multitasking
- Reliability
- Excellent Communication
- Organizational Skills
- Team Collaboration
- Active Listening
- Effective Communication
- Adaptability and Flexibility
- Task Prioritization
- Employee Motivation
Certification
Certified in CPR and CPR and AED through the American Heart Association.
References
Available upon request
Employmentskills
- Proficient understanding of medical terminology, health conditions, company policy provisions, state-specific regulations regarding licensures and benefits, and time requirements and examination procedures.
- Reviewing / approving of weekly Staff Timesheets.
- Approval of Staff PTO / EIB
- Experience with Medicaid/Medicare processing guidelines
- Familiar with both professional and institutional coding methodologies
- Good general insurance knowledge.
- Good verbal and written communication skills.
- CPT, HCPCS, and ICD-9 & 10 knowledge
- Ability to review and interpret policy contracts, provisions, riders and endorsements.
- Ability to make decisions and easily adapt to change.
- Attention to detail.
- Excellent organizational skills.
- Developed ability to work in a fast-paced atmosphere
- Maintained excellent customer relations and developed customer rapport
- Ability to work well with Hospital Liaisons, DME companies and vendors.
- Obtain information and accurately complete all documentation, forms and referral logs.
- Ability to follow instructions well and make decisions with no supervision
- Communicate with patient accounts to verify insurance and authorize care.
- Delegated responsibilities to employees to meet company’s expectations
- Effectively developed telephone communication skills
- Help resolve referral and admissions management issues & complaints through direct communication with referral sources and admissions team.
Timeline
Claims Operational Coordinator
Driscoll Health Plan
06.2023 - Current
Claims Supervisor
Driscoll Health Plan
04.2018 - 05.2023
Claims Supervisor
Valence Health
01.2015 - 03.2018
Claims Adjudicator Level II & Level III
Valence Health
09.2014 - 01.2015
Medicaid Customer Service Team Lead
Valence Health
08.2011 - 09.2014
Intake Coordinator/Insurance & Authorization Specialist
Interim HealthCare
10.2009 - 08.2011
Intake Coordinator
Christus Home Care-Spohn
10.2005 - 10.2009
Medical Office Coordinator
Christus Spohn PT & Rehab
09.2001 - 10.2005
Receptionist/ Billing Clerk
Spohn Home Care
09.1997 - 09.2001
Church’s Management School -
Church’s Management School
Taft High School -
Taft High School
Certified in CPR and CPR and AED through the American Heart Association.
Southern Careers Institute -
Southern Careers Institute
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