MARILITZA MUÑOZ-PEREZ
Altamonte Springs
Summary
Highly organized and detail-oriented worker, with a drive to exceed expectations. Ability to analyze data, develop strategies, and provide solutions to complex problems. Seeking to leverage skills and knowledge to contribute to team success. I want to continue to develop my knowledge and skills acquired during my work experience and years of study. Continue providing growth and fulfillment of goals in the company.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Claims Review Representative 3
Humana
07.2023 - Current
- Review by applying guidance, and making an appropriate decision which may include interpretation of provider information or data.
- Provided outstanding customer service and support to clients, resolving inquiries efficiently and effectively.
- Utilized knowledge of products and services to resolve customer issues efficiently and effectively.
Claims Configuration Analyst
Healthfirst
08.2021 - 07.2023
- Assist in the on-going evaluation of configuration for new and existing claims business rules including member benefits, claims editing, reference data and system functionality within the claims processing system
- Analyze explanation of coverage documents to assist with determining best approach for configuring benefits offered including member cost shares, deductibles, and out-of-pocket maximums
- Assist in the setup of code sets and defining pre-authorization guidelines used in claims configuration to drive application of medical policy and accurate claims payment
- Liaison with applicable departments to gather claims configuration requirements and provide feedback to stakeholders regarding feasibility of claims business rule and program changes
- Collect and analyze data to assess and resolve operational obstacles to claims configuration design optimization
- Perform root-cause analysis on claims configuration issues across all products, document results and present business impact analysis for proposed claims configuration changes
- Develop explanatory information for other departments to better understand claims configuration across products
- Identify ways to enhance performance management and operational reports related to new claims configuration processes
- Monitor existing system functionality and make claims configuration recommendations, where appropriate, to maintain acceptable levels of automation in claims adjudication and accurate claims payment
- Aid in the creation test scripts, including regression testing cases, to validate claims configuration against source documentation
- Assist with organizing the release of claims configuration changes to production to reduce the potential for migration conflict
- Ensure the quality and integrity of claims configuration change requests using production validation and audit strategies
- Provide project and informational updates to management as available and/or assigned
- Collaborate with business units to understand strategic goals and promote an environment conducive to creativity, change and information exchange.
QNXT Configuration Team Lead
Medicare y Mucho Mas, MMM Holdings, LLC
02.2015 - 08.2021
- Analyze and Design new Benefits and Contracts to configuration in QNXT (Annual Enrollment Period).
- Evaluate the SOP receive from Product Department to configure new Benefits in QNXT.
- Identify all requirements of limitations about any benefits to configure.
- Analyze all details of benefits and determine if have any update of Benefits to do in QNXT.
- Develop monthly and daily production output plans to deliver on other departments and compliance with the metrics
- Prepare detailed reports on updates to project specifications, progress, identified conflicts and team activities
- Audit of the configured products in the system of QNXT (Medicare Advantage) and PMHS (Medicaid)
- Update the fee schedules of the Medicare Advantage and Medicaid Line of Business for the Providers and Contracting Department for it to be uploaded in the providers portal Innova
- Evaluate employee skills and knowledge regularly, providing hands-on training and mentoring to individuals with lagging skills
- Design and configure the CES edits under requirements received by Optum
- Consult regularly with internal customers on application development project status, new project proposals, and software-related technical issues
- Design strategic plan for components in development practices to support future projects
- Deliver training and leadership to the team to boost performance and help the team members achieve the performance targets
- Mentor newly hired employees on Configuration and develop training manuals for reference purposes.
Claims Analyst III
First Medical, First Plus
05.2012 - 02.2015
- Process and audit payments of claims of participating, non-participating providers in Puerto Rico and the United States, for professional and institutional services
- Refer the findings from the result of the implementation of EZ-Cap system
- Analyze and process claims, meet production targets and quality, according to the benefits, laws, regulations, and fee schedules established by CMS and supplier contracts, reference books and internal policies
- Keep track of outstanding claims
- Perform the claims process using different payment methods such as: DRG, APC, ASC, Home Health, Physical Rehabilitation, ESRD Pricer, and Medicare Fee Schedule
- Ensure confidentiality of the information in the claims.
Claims Analyst II
Medical Card System
06.2009 - 02.2012
- Analyze and process claims, meeting production targets and quality, according to the benefits, laws, regulations, and fee schedules established by CMS and supplier contracts, reference books and internal policies
- Keep track of outstanding claims
- Process complaints received through redemption request, complaints, appeals and payment disputes
- Perform the claims process using different payment methods such as: DRG, APC and Medicare Fee Schedule
- Ensure confidentiality of the information in the claims.
Education
BBA - Business Administration / Management
Universidad De Puerto Rico -Cayey Campus
Accounting Degree - undefined
Josefa Pastrana High School
Skills
- Experience in Benefits Configuration and Provider Contract Configuration - QNXT / PMHS
- Knowledge and Experience in Clinical Edit System
- Systems Implementation, Configuration, Upgrading, Testing
- Monitoring and Evaluation (System and Claims)
- Business policies and procedures
- Process improvement
- Team training and support
- Knowledge in HIPAA Regulations, HCPCS, CPT
- ICD-10 CM, ICD-10 PCS
- Microsoft Office
- Medical Billing Cycle Certificate
- A lot experience in Claims Edit System with Optum
- Experience with run and analyze SQL Queries
- Certified Professional Coder by AFAMEP
Certification
Certified Professional Coder
Timeline
Claims Review Representative 3
Humana
07.2023 - Current
Claims Configuration Analyst
Healthfirst
08.2021 - 07.2023
QNXT Configuration Team Lead
Medicare y Mucho Mas, MMM Holdings, LLC
02.2015 - 08.2021
Claims Analyst III
First Medical, First Plus
05.2012 - 02.2015
Claims Analyst II
Medical Card System
06.2009 - 02.2012
Accounting Degree - undefined
Josefa Pastrana High School
BBA - Business Administration / Management
Universidad De Puerto Rico -Cayey Campus