Ruben Aguilar
Monterey Park,CA
Summary
Dedicated professional with extensive experience in healthcare claims processing and analysis. Known for strong attention to detail and problem-solving skills, contributing to timely resolution of claims and process improvements.
Overview
26
26
years of professional experience
Work History
Medical Claims Adjuster
Molina Healthcare
Long Beach , CA
04.2015 - Current
- Analyzed medical claims for accuracy and compliance with established policies.
- Processed claims using Molina Healthcare's electronic claims system efficiently.
- Instructed new adjusters on claims processes and company procedures to enhance team knowledge and efficiency.
- Achieved timely resolution of claims while preserving high quality standards.
- Participated in training sessions designed to keep current on industry-specific regulations.
- Assessed claim denials to determine if appeals are appropriate.
- Provided customer service support to healthcare providers regarding denied or disputed claims.
- Verified that payments were made according to contracted terms between provider and insurer.
- Analyzed medical claims for accuracy, completeness, and compliance with company policies and procedures.
- Examined inconsistencies in medical billing codes and claims processing data to ensure accuracy and compliance.
- Identified trends in claim rejections or denials and provided actionable feedback to management for process improvement.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
- Efficiently processed high volume of medical claims each shift.
- Basing payment or denials of medical claims upon well-established criteria for claims processing.
- Evaluated administrative guidelines whenever questions emerged during claims processing.
- Applied contract notes and processing manual to ensure precise application of group-specific classifications to claims.
- Inputted data into the system, maintaining accuracy of provider coding information and reported services.
Medical Claims Examiner
Molina Healthcare
Long Beach
08.2009 - 04.2015
- Processed medical claims for accuracy and completeness per established guidelines, ensuring timely payments.
- Reviewed medical claims for accuracy and compliance with company policies.
- Maintained up-to-date knowledge of healthcare regulations and reimbursement policies.
- Verified insurance coverage and eligibility of patients for services rendered.
- Validated that all necessary documentation was included with each claim submission.
- Determined payment or denial of medical claims based on established criteria.
- Determined the appropriate payment amount based on contractual agreements with providers.
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Formulated strategies to minimize claim denials related to incorrect coding and insufficient documentation.
- Ensured HIPAA compliance by maintaining strict confidentiality of patient information.
Medical Claims Examiner
Electronic Data Systems, EDS
Los Angeles, California
01.2000 - 08.2008
- Reviewed medical claims for accuracy and compliance with regulations.
- Processed claims using electronic systems to ensure timely adjudication.
- Coordinated with internal teams to resolve claim discrepancies, ensuring accurate and compliant processing.
- Maintained current knowledge of medical billing practices and policies to support accurate claims processing.
- Trained new staff on claims processing procedures and best practices.
- Collaborated with management to improve claims processing workflows and efficiency.
- Investigated discrepancies in claims data and reconciled errors.
- Ensured HIPAA compliance by maintaining strict confidentiality of patient information.
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Determined the appropriate payment amount based on contractual agreements with providers.
- Maintained updated knowledge of changes in healthcare regulations impacting claims processing.
- Provided training and guidance to new staff members on procedures related to claim processing.
- Validated that all necessary documentation was included with each claim submission.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Accurately processed large volume of medical claims every shift.
- Based payment or denials of medical claims upon well-established criteria for claims processing.
- Inputted data into the system, maintaining accuracy of provider coding information and reported services.
- Reviewed policies to determine appropriate coverage levels, facilitating informed approval or denial decisions.
Education
High School Diploma -
Garfield High School
Los Angeles, CA06-1994
Skills
- Claims processing and analysis
- Electronic claims processing
- ICD-10 coding
- Compliance auditing
- Health care compliance
Languages
English
Professional
Timeline
Medical Claims Adjuster
Molina Healthcare
04.2015 - Current
Medical Claims Examiner
Molina Healthcare
08.2009 - 04.2015
Medical Claims Examiner
Electronic Data Systems, EDS
01.2000 - 08.2008
High School Diploma -
Garfield High School