Mayra Garcia

• Reviewed and audited claims to identify errors or discrepancies in the documentation.
• Analyzed and validated claim data for accuracy, completeness, and compliance with applicable regulations.
• Investigated questionable claims to determine validity of payment requests.
• Identified trends in fraudulent or incorrect claims payments through analysis of audit results.
• Provided recommendations for corrective action on identified issues from audits.

Responsible for overseeing the entire claims processing department within a healthcare organization. This role involves managing the operation aspects of claims handling, ensuring compliance with regulatory requirements, and optimizing processes to enhance efficiency and effectiveness in claims management.

• Lead and manage a team of claims
• Claims Processing Oversight
• Process Improvement
• Training and Development

Responsible for overseeing and managing team of claims adjusters, to ensure performance and efficiently claims processing

• Monitored the performance of adjusters to ensure accuracy, timeliness and compliance with departmental standards.
• Provided training and guidance on best practices for handling new and existing claims.
• Analyzed data from previous claims to identify trends and areas for improvement.
• Resolved escalated customer issues by providing effective solutions in a timely manner.
• Prepared detailed reports on claim status and activities for management review.
• Ensured compliance with all applicable laws, regulations, policies and procedures related to claims processing.
• Collaborated with other departments to investigate potential coverage disputes or discrepancies.
• Negotiated settlement agreements between claimants and insurance companies when necessary.

Responsible for auditing claims, identifying discrepancies, and providing recommendations for improvements to enhance the efficiency of the claims process and benefits.

• Conduct thorough audits of healthcare claims to ensure compliance with internal policies.
• Analyze data related to claims processing, identifying trends, patterns, and potential areas of concern.
• Collaborate with management on complex claims reviews and resolutions
• Maintain accurate records of audit findings, including documentation support conclusions drawn during audits.

Evaluate claims payment based on established criteria such as contract, plans, and DOFR. Verify the accuracy of claims associated with the amount received for provider refunds. Identify overpayments and request relevant additional

information for recovery purposes.

• Maintain accurate records of audit findings, including documentation supporting conclusions drawn during audits.