Olga Solorzano
Rancho Cucamonga,CA
Summary
Diligent auditor with the understanding of researching claims processing errors and determining appropriate resolutions. Looking for a challenging position in an environment that offers opportunity for advancement and wanting to contribute to a department where quality overcomes quantity.
Overview
19
19
years of professional experience
Work History
Claims Auditor
Inland Empire Health Plan
07.2017 - Current
- Audited claims thoroughly to ensure payment was made according to contracts, policies and regulatory guidelines.
- Created overpayment requests due to payment inaccuracies and communicated trends to the department to eliminate further fraud, waste or abuse
- Processed provider refunds and retractions in its entirety up to adjusting claims to ensure accurate & efficient processing.
- Researched issues related to claims processing to identify the origin and implement corrective solutions.
- Job duties were expanded to Third Party Liability Liens working with our Legal & Compliance team to streamline the process
- Provided high level of professionalism when speaking with attorneys & or insurance companies to promote company's dedication to service & the commitment to recover funds.
- Prioritized daily tasks to satisfy workload demands and department's turnaround goals.
Business Analyst
Health Net, INC.
09.2014 - Current
- Ability to collect, analyze and present data to management identifying areas of improvement
- Analytical and problem solving skills and ability to conduct business studies and recommend solutions such as updating policies or providing training
- Knowledge of functional areas, policies, procedures, processes, and standards and helped review/audit & create policies & procedures for claims operations
- Demonstrate ability to prioritize and manage multiple responsibilities and deadlines, taking initiative and independence under minimal supervision in a fast-paced work environment
- Demonstrate ability to prioritize and manage multiple task, and meet deadlines with competing priorities
Audit Analyst
Health Net, INC.
04.2011 - 09.2014
- Performs routine and moderately complex audits to identify trends, issues, and exceptions to the established claims adjudication requirements
- Reports to management when quality standards impact the business unit, company, affiliates and/or clients and customers
- Proactively identifies performance trends/patterns of audits to management, and makes recommendations to improve quality, workflow processes, policies and procedures
- Provides timely review and completion on all contested claims
- Researches claim processing problems and errors to determine their origin and provides appropriate feedback to examiners, trainers and management
- Manually enters audit data into the database to develop reports based on the audit findings
- Provides coaching and feedback to examiners and management on prepayment and post payment findings and trends
- Provides recommendations for additional training or updates that will help prevent further errors to enhance service and productivity within Health Net
- Maintains a comprehensive working knowledge of Policies, Procedures, Compliance Regulations, Schedule of Benefits and turn around times across all product lines
- Participates in specialized training within departments
- Monitors daily assignments and prioritizes aged audits to ensure all audits are completed timely per regulatory and department guidelines
- Performs other related duties as assigned
Claims Examiner
CAP Management Systems Tenet
11.2010 - 04.2011
- Adjudicate claims using the IMAX and EZ-Cap system
- Customize an IPA's payment of a claim based on the Health Plan's contract, provider's contract, member's eligibility and the member's benefits
Claims Examiner
Health Net, INC.
06.2006 - 08.2010
- Primary duties included determining proper handling of medical claims submitted in the HMO line of business both manual and electronic claims
- Based on positive performance my duties were expanded to handling claims across multiple lines of business including HMO, PPO, POS, Indemnity, Medicare, FFS and the pilot Latino product through both UBO4's and HICFA 1500's including electronic, paper and manual claims
- Received multiple certificates and awards due to my job performance based on my efficiency and completing claims and special assignments in a timely manner
- Reviewed policies & procedures to process claims accordingly.
Administrative Support Assistant
Kelly Services
03.2006 - 06.2006
- Primary duties included placing calls to providers to obtain additional or missing claims information for an examiner to process claims accurately.
- Additional duties included pricing through software such as Multiplan and National Care Network (NCN) to aid claims examiners in achieving optimal rates.
Education
Certified Medical Biller/Claims Examiner -
Adelante Career Institute
Panorama City, CA01.2006
High School Diploma -
Ulysses S. Grant High School
Valley Glen, CA01.2005
Skills
- MS Office (Excel, Word, PowerPoint, Outlook)
- Strong knowledge of coding systems (CPT, ICD9/10)
- Knowledge of DOFR (Division of Financial Responsibility)
- Knowledge of DTR (Desktop Reference)
- Strong knowledge in auditing and identifying trends
- Manages workflows and meets deadlines
- Prioritize and manages multiple responsibilities
- Works independently and as a team player
- Highly trainable & fast learner & adapts well to change
- Great communication skills both verbal & written
- Diamond Claims System
- Meditrac Claims System
- HRP/First Source Claims Covered CA System
- ABS Claims System
- Macess EXP Claims System
- Pricing (Webstrat, Burgess, First Health, Multiplan, Beech Street, NCN, Stratose)
- Bilingual (English & Spanish)
Timeline
Claims Auditor
Inland Empire Health Plan
07.2017 - Current
Business Analyst
Health Net, INC.
09.2014 - Current
Audit Analyst
Health Net, INC.
04.2011 - 09.2014
Claims Examiner
CAP Management Systems Tenet
11.2010 - 04.2011
Claims Examiner
Health Net, INC.
06.2006 - 08.2010
Administrative Support Assistant
Kelly Services
03.2006 - 06.2006
Certified Medical Biller/Claims Examiner -
Adelante Career Institute
High School Diploma -
Ulysses S. Grant High School
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