Patricia (Trish) Almanza
El Paso,TX
Summary
Senior Claims Representative with 15 years of industry experience. Successful at meeting customer and company needs with fair and equitable approach to claims process. Detail-oriented, systematic and skilled in identifying exposures and proposing actionable solutions.
Overview
20
20
years of professional experience
Work History
Senior Claims Representative
Claims Administrative Services, Inc.
El Paso, TX
05.2013 - Current
- Conducted investigations into complicated mid- and high-exposure claims.
- Recommended and set reserves based on expected payouts.
- Collaborated with legal department on important claims.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
- Verified client information by analyzing existing evidence on file.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Manage and monitor medical treatment on all open claims and that the treatment complies with the Official Disability Guidelines
- Initiate benefits in a timely manner
- Secure recorded statements
- Review medical bills, medical reports, pharmacy requests
- Keep updated diaries on all open claims
- Request Designated Doctor evaluations, Required Medial Evaluations, Benefit Review Conferences, Contested Case Hearings, and Case managements on all files when needed
- Open communication with clients with respect to investigation of all claims, disputes, or handling claims
Cashier/ Sales Associate
Burlington
El Paso, TX
03.2023 - 12.2023
- Enhanced customer satisfaction by providing efficient and accurate cash transactions.
- Streamlined checkout process for increased efficiency and reduced waiting times.
- Assisted customers with inquiries and provided exceptional service, resulting in positive feedback from shoppers.
- Collaborated with team members to achieve sales targets and maintain a clean, well-stocked store environment.
- Handled multiple payment methods securely, minimizing discrepancies and potential losses.
- Mentored new employees on cashier duties and best practices, improving overall staff performance.
Senior Claims Representative
1-2-1 Claims, Inc
El Paso, TX
09.2011 - 05.2013
- Conducted investigations into complicated mid- and high-exposure claims.
- Recommended and set reserves based on expected payouts.
- Generated, posted and attached information to claim files.
- Verified client information by analyzing existing evidence on file.
- Carried out administrative tasks by communicating with clients, distributing mail and scanning documents.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Reviewed outstanding requests and redirected workloads to complete projects on time.
- Communicated effectively with staff members of operations, finance and clinical departments.
- Checked documentation for accuracy and validity on updated systems.
Senior Claims Representative
Claims Administrative
El Paso, TX
07.2008 - 09.2011
- Conducted investigations into complicated mid- and high-exposure claims.
- Recommended and set reserves based on expected payouts.
- Collaborated with legal department on important claims.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
- Verified client information by analyzing existing evidence on file.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Manage and monitor medical treatment on all open claims and that the treatment complies with the Official Disability Guidelines
- Initiate benefits in a timely manner
- Secure recorded statements
- Review medical bills, medical reports, pharmacy requests
- Keep updated diaries on all open claims
- Request Designated Doctor evaluations, Required Medial Evaluations, Benefit Review Conferences, Contested Case Hearings, and Case managements on all files when needed
- Open communication with clients with respect to investigation of all claims, disputes, or handling claims
Claims Adjuster
NovaPro Risk Solutions
El Paso, TX
06.2006 - 07.2008
- Conducted investigations into complicated mid- and high-exposure claims.
- Recommended and set reserves based on expected payouts.
- Collaborated with legal department on important claims.
- Resubmitted claims after editing or denial to achieve financial targets and reduce outstanding debt.
- Verified client information by analyzing existing evidence on file.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Manage and monitor medical treatment on all open claims and that the treatment complies with the Official Disability Guidelines
- Initiate benefits in a timely manner
- Secure recorded statements
- Review medical bills, medical reports, pharmacy requests
- Keep updated diaries on all open claims
- Request Designated Doctor evaluations, Required Medial Evaluations, Benefit Review Conferences, Contested Case Hearings, and Case managements on all files when needed
- Open communication with clients with respect to investigation of all claims, disputes, or handling claims
Worker's Compensations Pre-Certification Clerk
El Paso Orthopaedic Surgery Group
El Paso , TX
11.2004 - 06.2006
- Responsible for preauthorization on surgeries for 24 doctors
- Working with different insurance companies(adjusters) on patient's claims.
- Verify workers' compensation claims
- Working with the local Texas Workers' Commission Division on patient's claims that were pending BRC's, CCH's, and MDR's.
- Flagging patients accounts with Peer reviews, IMES, or RME's
- Billing
- Giving and collecting estimates for self insured (non-subscribers workers' comp claims
Education
No Degree - General Studies
El Paso Community College
El Paso, TXHigh School Diploma -
Parkland High School
El Paso, TX05.1994
Skills
- High exposure claims experience
- Reserve planning knowledge
- Investigations expertise
- Documentation abilities
- Great mathematical skills
- Reporting skills
- Understanding of medical terms
- Patient contact
- Prior authorization processing
- Excellent administrative abilities
- Interpersonal Communication
- Data integrity
Languages
Spanish
REFERENCES
- Cruz Gandarilla 915-539-0361
- Dr. Richard Westbrook 915-313-6300
- Chris Eagle 512-517-3528
- Sam Attel 915-329-3452
Timeline
Cashier/ Sales Associate
Burlington
03.2023 - 12.2023
Senior Claims Representative
Claims Administrative Services, Inc.
05.2013 - Current
Senior Claims Representative
1-2-1 Claims, Inc
09.2011 - 05.2013
Senior Claims Representative
Claims Administrative
07.2008 - 09.2011
Claims Adjuster
NovaPro Risk Solutions
06.2006 - 07.2008
Worker's Compensations Pre-Certification Clerk
El Paso Orthopaedic Surgery Group
11.2004 - 06.2006
No Degree - General Studies
El Paso Community College
High School Diploma -
Parkland High School