Ruby Holguin-Robles

• Perform Quality Audits of Commercial Cigna claims from billing providers and facilities
• Enhance claims processing accuracy by conducting thorough quality audits and providing feedback to claims examiners.
• Finalize claims for insurance payment or denial release

• Provide status, research and resolve discrepancies of Cigna Post-Service Provider Claim Appeals
• Multitask through various applications while working through dual operating platforms.
• Respond to high volume inquiries and escalated requests received by phone and email.
• Assist in training of new hires, creating and maintaining job aids as well as being the POC for team questions.

• First point of contact for Facilities, Physician Offices and Patients looking to initiate Prior Authorizations for High-Tech Radiology, MSK Procedures, Cardiac, DME and Sleep Services.
• Worked with such individuals to create, investigate and complete any Precertification requests by phone
• Sent these Precertification requests to additional clinical reviewers when necessary

(Remote Position)

• Processed as well as audited High Dollar Claims submitted by providers for reimbursement amounts of between $50-$500k.
• Trained new hires, managed inventory and acted as the point of contact for the Department to resolve errors and answer questions.
• Responsible for high profile claims that require special handling such as Transplant, Dialysis, Pay to Subscriber claims and Travel Reimbursement.
• Processed PCP, Specialty and Hospital claims according to a variety of individual contracts for both Medicaid and ASO arrangements servicing the State of New Mexico.
• Assisted other teams with different projects as assigned including Centennial Care, Medicare, Reclamation, and Care Unit claims processing backlogs

• Responsible for closing pharmacy claims, being the last point of contact for approval or denial of requested medications
• Analyzed Patient and Physician Information was entered correctly using applications such as Rx Claims and Cover My Meds
• Created and submitted Prior Authorization's for specific Utilization Management Programs per client and member contracts
• Ran Test Claims, verified end results for each review, and closed cases

• Managed payroll processing, new hire and termination procedures for a full service hotel
• Processed various garnishment's, including child support, and tax levies and verified correct amounts were deducted from employee wages per pay period
• Oversaw day-to-day processing of payroll for 100+ employees, including review of time sheets and computing pay in accordance with FLSA
• Generated paper checks for employees and printed stubs for associates who received direct deposits to complete payroll distribution.

• Managed payroll processing, new hire and termination procedures for a full service hotel
• Processed various garnishment's, including child support, and tax levies and verified correct amounts were deducted from employee wages per pay period
• Oversaw day-to-day processing of payroll for 100+ employees, including review of time sheets and computing pay in accordance with FLSA
• Generated paper checks for employees and printed stubs for associates who received direct deposits to complete payroll distribution.

• Accomplished Bookkeeping, errands, and standard clerical duties for a small personal business
• Prepared packages for shipment, pickup and courier services for prompt delivery
• Performed general office duties, including answering multi-line phones, routing calls and messages and greeting visitors
• Developed and updated spreadsheets and databases to track, analyze and report on performance
• Processed invoices and expenses using Wave Accounting Software

• Managed check in/out process using Opera Software. Acted as shift leader managing employees as well as high importance groups and events
• Maintained financial accuracy by collecting deposits, fees and payments
• Handled complaints and billing discrepancies
• Enforced security policies and removed violators and unauthorized individuals from premises to maintain safe environment

• Calculated and prepared weekly check runs for utilities, taxes, and other vendors
• Calculated, prepared, and issued bills, invoices, and account statements according to established procedures for Accounts Receivable
• Applied proper codes to invoices, files and receipts to keep records organized and easily searchable
• Performed targeted collections on past due accounts aged over 30 days.

• Regularly monitored vital signs, wound care, catheter care, practiced medical terminology, performed medication management and record filing
• Monitored, tracked and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery
• Facilitated activities of daily living, including personal hygiene management, feeding and attaining ambulation
• Scheduled and accompanied family member/client to and from medical appointments

Payroll Specialist November 2018-August 2019

Accounts Payable/Receivable Clerk January 2016-July 2018

Hotel Receptionist April 2015-January 2016

(More extensive resume available upon request for full Job History)