MAYRA VALDES
Hialeah,FL
Summary
Accomplished Claims Examiner with over 15 years of experience in processing Managed Health Care Insurance claims. Accountable for quality production, adjudication, and processing claims timely. Extensive knowledge of hospital and medical claims processing systems, procedures, policies, and corporate guidelines. Dedicated with strong communication, written and verbal skills. Ability to perform in a high production environment, work independently to exceed departmental productivity and quality standards. Able to complete assigned tasks in a timely manner and efficiently.
Overview
23
23
years of professional experience
Work History
Claims Examiner
NEBA
04.2018 - Current
- Carefully gathered all facts before making final determination on any claim with accurate decision-making skills
- Met or achieved set targets consistently, strictly adhering to individual and departmental standards with regard to both quality and productivity
- Gained experience across appropriate codes, health insurance principles, medical terminologies, subrogation, reinsurance, compensation, third party liability, and coordination of benefits claims.
Claim Examiner III
Emblemhealth Administrators
04.2010 - 02.2017
- Carefully gathered all facts before making final determination on any claim with accurate decision-making skills
- Met or achieved set targets consistently, strictly adhering to individual and departmental standards with regard to both quality and productivity
- Responsible for Accurate adjudication of facility claims for Medicare, Medicaid and Commercial lines of business to include all areas of specialization and meeting productivity, quality and performance standards
- Project assistance for APG, APC claims to identify over/under payments and review of reports to finalize and process voids, adjustments, and release of higher level appeal claims.
Claims Examiner II
Emblemhealth Adminmistrators
03.2005 - 03.2010
- Met or achieved set targets consistently, strictly adhering to individual and departmental standards with regard to both quality and productivity
- Carefully gathered all facts before making final determination on any claim with accurate decision-making skills
- Re-investigated questionable claims to identify any signs of fraud and protect the company from paying out incorrectly.
Claims Examiner I
Emblemhealth Administrators
04.2001 - 06.2005
- Gained experience across appropriate codes, health insurance principles, medical terminologies, subrogation, reinsurance, compensation, third party liability, and coordination of benefits claims
- Met or achieved set targets consistently, strictly adhering to individual and departmental standards with regard to both quality and productivity
- Assessed policy details to determine accurate coverage interpretation and prepared appropriate coverage letters for approval by the claims management team.
Education
High School Diploma -
Hialeah High School
Hialeah, FLCoding and Billing -
Unique Career Academy
Miami Lakes, FLSkills
- Data verification
- Healthcare procedures
- Determine coverage
- Document and policy review
- Check claims
Timeline
Claims Examiner
NEBA
04.2018 - Current
Claim Examiner III
Emblemhealth Administrators
04.2010 - 02.2017
Claims Examiner II
Emblemhealth Adminmistrators
03.2005 - 03.2010
Claims Examiner I
Emblemhealth Administrators
04.2001 - 06.2005
High School Diploma -
Hialeah High School
Coding and Billing -
Unique Career Academy
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