Melany Luna
Phelan,USA
Summary
Effective Medical Claims Auditor with strong background building rapport with providers to discuss claim status, underpayments, overpayments or claim denials. Driven performer equipped to handle multiple administrative tasks effectively. Exemplary worker with highly investigative skills when processing and Auditing claims. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 8 years of experience and willingness to take on any challenge.
Overview
9
9
years of professional experience
Work History
Transportation Coordinator
Inland Empire Health Plan
Rancho Cucamonga, CA
02.2023 - 09.2025
- Responsible for monitoring the Right Fax Server. Ensuring all referrals are processed in a timely manner and ensuring compliance with appropriate turnaround timeframes.
- Responsible for checking the referral form for completeness, obtaining missing demographic information as needed, and initial attempts at coding any uncoded referrals.
- Implemented efficient routing strategies to optimize resource allocation and reduce delays.
- Managed scheduling systems to streamline operations and maximize vehicle utilization across service areas.
- Coordinated transportation logistics to ensure timely patient access to healthcare services.
- Managed high-volume calls and provided timely solutions to enhance customer satisfaction.
Claims Auditor
Loma Linda University Health Care
San Bernardino, CA
09.2020 - 01.2023
- Audits claims, examining and processing complex and high-dollar institutional and professional claims
- Implementation of corrective action plans through future audits to ensure compliance
- Auditing claims in a managed care environment
- Contract and financial DOFR interpretation for all Commercial insurances, Medi-Cal, Medi-Cal Managed Care, and Medicare.
- ICD-9/ ICD-10 and CPT coding and general practices of claims processing
- CMS/DMHC and Affordable Care Act regulations and guidelines
- Conducted comprehensive audits of claims to ensure accuracy and compliance with regulations.
- Adjusting first-pass and post-pay claims that result in overpayment or underpayment due to claim processing system issues, contract amendments, processing errors, or other issues
- Knowledge of benefits claim processing, claims principles, medical terminology, diagnosis, and procedures and HIPAA regulations.
- Identified discrepancies in claims processing, leading to improved resolution protocols.
- Researched issues related to claims processing to identify origins and implement corrective solutions.
- Commercial line of business Covered California/Exchange
- Reviewed accounts on monthly basis to assess aging and pursue collection of funds.
Accounts Receivable Specialist
Vista Medical Group
Corona, CA
06.2017 - 06.2020
- Adjudicated medical claims in accordance with payer guidelines, provider contracts, and regulatory requirements
- Applied contract pricing and fee schedules to ensure accurate reimbursement
- Identified and resolved claim edits, denials and exceptions
- Applied contract pricing and fee schedules to ensure accurate reimbursement
- Managed efficient cash flow reporting, posted cash receipts and analyzed chargebacks, independently addressing and resolving issues
- Workers Compensation, CCMS1500 claim forms, entry data, processing EOB’s
- Reviewed accounts on monthly basis to assess aging and pursue collection of funds.
Billing Analyst
Alcam Medical Orthotics And Prosthetics
Riverside, CA
11.2016 - 12.2017
- Conducted monthly pre-billing review and data quality analysis to verify complete accuracy of invoices delivered to customers and providers.
- Implemented proper execution of monthly collection letters and escalation process.
- Submitted alternate billing for clients belonging to special demographics using EPIC software portal, reconciled EOBs or denied claims and conducted accounts receivable follow-up.
- Partnered with billing analyst department to investigate and remedy any gross margin trend issues.
- Communicated with insurance providers to resolve denied claims and resubmitted.
- Reviewed Medical Records for patients, identified medical codes and created invoices for billing purposes.
- Trained new employees on multiple medical billing programs and data entry software.
Education
Associate Degree - Nursing
American Career College
Ontario, CA06-2017
Skills
- Overpayment identification
- Data analytics
- Excellent analytical, critical thinking, customer service, and organizational skills
- Commercial line of business
- Aging report evaluation
- Claims auditing
- ICD-9/ ICD-10 and CPT coding
- Proficient in MedHok/EPIC Management
- HIPAA compliance awareness
- CMS/DMHC and Affordable Care Act regulations and guidelines
VOLUNTEER EXPERIENCE
- CHOC, Christmas Toy Drive
- U-REACH ORGANIZATION, Food Drive
Languages
Spanish
Native or Bilingual
Timeline
Transportation Coordinator
Inland Empire Health Plan
02.2023 - 09.2025
Claims Auditor
Loma Linda University Health Care
09.2020 - 01.2023
Accounts Receivable Specialist
Vista Medical Group
06.2017 - 06.2020
Billing Analyst
Alcam Medical Orthotics And Prosthetics
11.2016 - 12.2017
Associate Degree - Nursing
American Career College