Summary
Overview
Work History
Education
Skills
Languages
Timeline
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Tania Reyes

Miami

Summary

Talented, responsible, individual who can independently handle daily functions and meet customer needs.

Professional with strong background in medical claims management, adept at navigating complex insurance processes and ensuring accurate claim resolution. Known for fostering team collaboration and driving impactful results, consistently adapting to changing industry needs. Possess key skills in claims assessment, regulatory compliance, and process optimization, coupled with reliable and flexible approach to leadership.

Overview

19
19
years of professional experience

Work History

Overseas Medical Claims Supervisor

Geoblue
07.2024 - Current
  • Within working three months, I was able to clean out seven months of backlog work related to CMRP routes.
  • Didn’t receive any training class. Was able to learn on my own the claims department’s system, policies and procedures.

Overseas Medical Claims Manager

GMMI
05.2015 - 06.2024
  • Managed and worked as a SIU (Special Investigation Unit) handling claims for potential FWA (fraud, waste and abuse).
  • Researched providers, medical claims, medical reports for potential fraud, waste and abuse. Extensive research on providers and potentially on members for any articles, news found online related to any compliance fraud.
  • Worked and handled on my own all OFAC claims, following the regulation guidelines.
  • Created the entire SOP (Standard Operational Procedure), trainings for each department within the claims team.
  • Successfully saved over $2.5 Million annually for the company by auditing international claims where I was able to find charges where they were not within the usual, customary and reasonable and successfully obtain discounts or corrective claim from international providers

Intake Specialist

Altegra Health
10.2013 - 08.2014
  • Meet production and quality goals by conducting telephone outreach to review member’s eligibility
  • Screened Medicare members in order to meet financial qualifications for the Medicare’s Savings Plan and other programs
  • Maintain current knowledge of state and federal regulatory requirement to adhere to strict compliance.
  • Increased customer satisfaction with timely follow-ups, ensuring all necessary documentation was collected and processed promptly.

Medical Coordinator / Senior Claims Processor

Federal Assist
12.2005 - 11.2012
  • Coordinated house-call doctors, specialist, ER visits, surgeries, funeral services and repatriation
  • Request health records and claims from medical providers
  • Duties involved data entry, an average of 120 medical claims received via mail and fax daily
  • Process medical claims and obtain the best discount possible by negotiating with medical providers
  • Enhanced patient care by efficiently coordinating medical services and streamlining communication between healthcare professionals.

Education

Certified Medical Coder -

Medical Coding Academy
Tampa, FL
12.2017

Medical Coding Certificate - undefined

Florida Technical College
Pembroke Pines, FL
07.2016

Skills

  • Analytical Skills
  • Time Management
  • Verbal and written communication
  • Complex Problem-Solving
  • Fraud, Waste and Abuse
  • MS Office
  • OFAC
  • Reliable
  • Medical Terminology
  • Organized
  • Creating Reports
  • Independent learner
  • Create and present PowerPoints
  • Strong decision-making

Languages

English
Spanish

Timeline

Overseas Medical Claims Supervisor

Geoblue
07.2024 - Current

Overseas Medical Claims Manager

GMMI
05.2015 - 06.2024

Intake Specialist

Altegra Health
10.2013 - 08.2014

Medical Coordinator / Senior Claims Processor

Federal Assist
12.2005 - 11.2012

Medical Coding Certificate - undefined

Florida Technical College

Certified Medical Coder -

Medical Coding Academy

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Tania Reyes