Ramon Joson
Long Beach
Summary
Results-driven Claims Auditor with extensive experience at Alignment Health, specializing in risk assessment and compliance. Proficient in ICD 10 and data analysis, I excel in identifying trends and implementing corrective actions. My strong problem-solving skills have led to improved audit accuracy and enhanced training initiatives across teams.
Overview
10
10
years of professional experience
Work History
Delegation Oversight Claims Auditor
Alignment Health
Orange
05.2023 - Current
- Conduct annual risk assessment of delegated entities; develop the delegated entity claims annual audit plan
- Schedule and maintain the claims audit schedule
- Conduct audit of case file samples and other supporting documentation against CMS, claims processing standards, and other established criteria
- Analyze audit results and produce a complete and concise audit report
- Issue corrective action requests where required
- Ensure corrective action plan responses are properly developed and follow-up items are completed according to agreed-upon deadlines.
- Conduct validation audits as needed.
- Review audit finding trends to identify training opportunities; collaborate with the DO Manager to draft training documents for distribution
- Create and maintain accurate, complete, and current audit records
- Participate in CMS and/or other regulatory audits as needed
Claims Supervisor
Network Medical Management /Apollo Medical Holdings
01.2022 - 04.2023
- Training and supervision of Claims Clerks and Claims Examiners; Evaluation of productivity and claim production quality;
- Claim Inventory Control;
- Check Run Coordinator;
- Weekly claim department reports.
- Assessment of possible overpayments or Third Party Liability potential.
- Claim database updates such as contracts and fee schedules. issuing system generated approved Claim Denial Letters
- Addressing and documenting claim staff issues.
Claims Auditor
Prospect Medical Holding
07.2020 - 12.2021
- Perform analysis and monitor trends identified through the audit process.
- Ensure accurate and timely adjudication of claims, as well as identifying potential issues and recommending strategies for resolution.
- Apply claim and/or inquiry processing experience to audit and analyze simple to advanced-level claims processing procedures and workflows.
- Independently run reports on errors identified for potential error trends and report the results to Claims Management and Claims Trainer.
- Assisted processing of PDRs, Health Plan Cap Deducts, and claims processing.
- Handle special projects from external provider and internal departments. Must have the ability to accurately make the necessary adjustments for underpayments and review overpayment requests for Claims Recovery Specialist.
- Independently audit and analyze high dollar claims and checks prior to the issuance of funds.
- Analyzed and prepared Health plan claims selections for Annual health plan audit.
- Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor is present at the time of audit.
- Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests. Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.
Compliance and Regulatory Senior Auditor
Monarch Healthcare, part of Optum
04.2018 - 07.2020
- Conducts pre and post claim audits for Medicare, Commercial and Medi-Cal line of business for Monarch Health Plan, routine and moderately complex audits on paper and electronic claims for payment integrity.
- Claim processing problems and errors to determine their origin and appropriate resolution.
- Prepared reports and summarized observations.
- Identified and escalated issues related to instructional material that is inaccurate, unclear or contains gaps.
- Provided recommendations for corrections.
Claims Audit Specialist
WellCare Health Plans
04.2016 - 03.2018
- Auditing Medicare Claims for Easy Choice Health Plan (work from home) and Cypress, CA.
- Performed end to end audits of Operational area to ensure accuracy of departmental processes.
- Daily quality reviews of operations department processes (i.e. eligibility, enrollment, claims processing and pricing, configuration contract loads, etc).
- First and second level rebuttals in a timely manner.
- Tracked and maintained quality results for appropriate distribution.
- Communicates audit results in a structured report format.
Education
Bachelor of Science - Business Administration major in Accounting
University of the East
Manila, PhilippinesSkills
- ICD 10
- CPT coding
- DRG
- Contracts
- DOFR
- EZ Cap
- IDX
- Qnext
- Various legacy systems
- Problem solving
- Data analysis
- Regulatory compliance
- Trend analysis
- Claims processing
- Risk assessment
- Compliance and regulations
- Claims auditing
Awards
- Bravo Awards for Collaboration, 2018
- Collaboration for EZ Cap Testing and Upgrade, 2019
- Featured in Kaiser Newsletter 'Making a Difference', 2008
- Achievement award from Cedar Sinai Health Systems, 1998
- 'Star Awards' (FHP) for productivity, accuracy, and team planning, 1992
Professional Skill Sets
- Proficient in ICD 10, CPT coding, DRG, contracts, DOFR
- Familiar with EZ Cap, IDX, Qnext, and various legacy systems
- Problem solving
Timeline
Delegation Oversight Claims Auditor
Alignment Health
05.2023 - Current
Claims Supervisor
Network Medical Management /Apollo Medical Holdings
01.2022 - 04.2023
Claims Auditor
Prospect Medical Holding
07.2020 - 12.2021
Compliance and Regulatory Senior Auditor
Monarch Healthcare, part of Optum
04.2018 - 07.2020
Claims Audit Specialist
WellCare Health Plans
04.2016 - 03.2018
Bachelor of Science - Business Administration major in Accounting
University of the East