Ashley Aponte
Los Angeles,CA
Summary
Claims Examiner with 6+ years of experience processing Medicare, Medi‑Cal, and commercial claims in a delegated MSO environment. Known for accuracy, trend identification, and strong collaboration with cross‑functional teams to improve claims quality. Demonstrates long‑term dedication to employers, with a proven history of staying in roles for extended periods and growing within the organization.
Overview
14
14
years of professional experience
Work History
Claims Examiner II
Altura MSO
Montebello, CA
06.2023 - Current
- Evaluates and approves, denied, or adjusted claims in accordance with policy provisions and regulatory standards.
- Investigating questionable or complex claims to verify facts and detect potential fraud.
- Ensure accuracy of claim files, notes, and documentation for audit compliance.
- Process second‑level claims, including adjustments and corrected claims.
- Identify trends in improper processing and escalate to leadership for corrective action.
- Ensure all claim handling activities adhere to federal/state regulations and internal policies.
- Meet productivity, accuracy, and quality standards.
Provider Dispute and Resolutions Coordinator
California Promise Health Plan
10.2018 - 06.2023
- Reviewed and processes provider appeal and dispute determination according to CMS, contractual and processing guidelines. Issue appropriate documentation and payments accurately and timely.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
- Meets and consistently maintains quality and productivity standards as defined by Management.
- Interpret DOFR and contracts to review appeals to process or uphold.
- Process Medi-Cal Professional claims for payment according to contract, LOA, or Medi-Cal fee schedule.
- Creates episodes in AuthAccel for nurses to review for authorization.
- Identify and disputed cases that are not true appeals to appropriate departments such as the Recovery, Claims, Special Investigations Unit and Optum department.
Provider Data and Configuration Management
Care 1st Health Plan
Monterey Park, CA
05.2014 - 10.2018
- Enters provider’s data in MHC database for all In Network and Out of Network Providers.
- Reviews contracts and applications prior to data implementation to ensure validity.
- Report all database issues to the Supervisor, Data Management in a timely and effective manner. Work with IT to resolve database issues when necessary.
- Participates in the testing of data during database upgrades and conversions.
- Conducts database clean up as requested.
Medical Biller
Tze Yu Dang, M.D
11.2013 - 06.2014
- Communicated with insurance providers to resolve denied claims and resubmitted.
- Prepared billing statements for patients and verified correct diagnostic coding.
- Reviewed patient records, identified medical codes and created invoices for billing purposes.
- Liaised between patients, insurance companies and billing office.
- Collected payments and applied to patient accounts.
Veterinary Assistant
LA Central Animal Hospital
03.2012 - 08.2013
- Answered owner animal health questions and advised on best care practices.
- Triaged incoming patients to determine treatment needs and urgency of care.
- Collected patient biopsies and blood samples for laboratory analysis.
- Positioned animals for diagnostic imaging such as x-rays and scans.
Education
Medical Billing And Coding
Everest College - Alhambra
Alhambra, CA08.2013
High School Diploma -
El Rancho High School
Pico Rivera, CA07.2006
Skills
Strong knowledge of Medicare, Medicaid/Medi‑Cal, and commercial claims processing
Proficiency in CPT, HCPCS, ICD‑10, and revenue codes
Understanding of pricing methodologies (Medicare/Medi‑Cal fee schedules, DRG)
Experience with claims processing systems and Microsoft Office
High attention to detail and accuracy
Ability to manage high‑volume workloads and competing priorities
Timeline
Claims Examiner II
Altura MSO
06.2023 - Current
Provider Dispute and Resolutions Coordinator
California Promise Health Plan
10.2018 - 06.2023
Provider Data and Configuration Management
Care 1st Health Plan
05.2014 - 10.2018
Medical Biller
Tze Yu Dang, M.D
11.2013 - 06.2014
Veterinary Assistant
LA Central Animal Hospital
03.2012 - 08.2013
Medical Billing And Coding
Everest College - Alhambra
High School Diploma -
El Rancho High School