Theresa Wilson
Long Beach,California
Summary
To bring my proven skills to a professional organization that will allow me to utilize the full extent of my abilities and encourages creativity for problem solving and growth. Highly-motivated employee with desire to take on new challenges. Strong work ethic, adaptability, and exceptional interpersonal skills. Adept at working effectively unsupervised and quickly mastering new skills.
Overview
23
23
years of professional experience
Work History
Medical Claim Examiner
Kore1 Temp Agency/MemorialCare Medical Foundation
Fountain Valley, CA
06.2023 - Current
- Documents resolution of claims to support claims payment and or decision
- Ability to identify and report processing inaccuracies that are related to system configuration
- Reviews processes and adjudicates claims for payment accuracy or denial of payment according to the Department’s policy and procedures
- Process all claims accurately conforming to quality and production standards and specification in a timely manner
- Ability to prioritize multitask and manage claims assignment with department goals and regulatory compliance and with minimal supervision
- Ability to make phone calls to Provider/Billing Offices, when necessary, based on department guidelines
- Requests additional information or follow up with provider for incomplete or unclean claims
- Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines
- Assist in Customer Service
Claims Payment Specialist
Liberty Dental Plan
Tustin, CA
04.2023 - 06.2023
- Daily Report via email from different account assigned to me to start the printing process
- Information is filled into the Excel spreadsheet
- Blank Check are pull and log in the Checkout log, Enter check numbers onto the Excel spreadsheet for each account
- Each account I printed a certain number of checks ranging from 1 to 400 or more
- I pull one account at a time to print checks and cover sheets
- Log the amount of each check into the Deposit log
- Claims Payable Email answered emails
- Capitated check runs once a month.
Medical Claim Analyst
HealthCare Support/Optum Health Care
Colorado City, CO
09.2021 - 08.2022
- Researched and processed moderate to complex claims
- Handles challenging situations and acts with appropriate level of urgency when necessary
- Follow precise instructions when processing claims
- Completes assigned work and maintains production and quality standard
- Process claims both paper and electronic and follow CMS guidance
- Applies specific and market focused processes to provide service support to clients as needed.
Medical Claim Examiner
The Judge Group/ Hoag Memorial Hospital Presbyterian
Costa Mesa, CA
12.2020 - 07.2021
- Process medical claims meeting key metrics on productivity, financial accuracy, and regulatory compliance
- Confirm patient eligibility and apply Coordination of Benefits guidelines by partnering with the Enrollment and Eligibility team
- Interpret and administer member benefits, contract terms with medical providers, utilizes various fee schedules and payment terms (FFS, case rates, exclusions, carve-outs, capitation, per diems, stop loss, etc.) and health plans/Division of Financial Responsibility
- Forward claims that fall under the health plan risk Review claims in pending status and request additional information required to resolve unclean or contested claims
- Administer timely filing guidelines for contracted and non-contracted providers rejecting claims submitted untimely and reviewing proof of timely filing documentation from providers
- Apply regulatory and industry guidelines in claims adjudication including timely processing, clear and concise language, required communication to providers and patients
- Interact in a positive and collaborative manner
- Alert the claims management team of issues and trends observed in the claim adjudication process
- Resolve requests from providers, patients, and health plans on claims questions or issues
- Up port the claims team in implementing initiatives in improving claims processing efficiency
- Perform other duties as assigned
- Assist PDR claims.
Provider Configuration Analyst
Vincent Benjamin Temp Agency/Prospect Medical Group
Orange, CA
05.2020 - 10.2020
- Maintaining provider dictionaries, vendor contracts, fee schedules and capitation agreements in the managed care system
- Daily operational activities which will ensure successful and accurate claims and capitation payment to various contracted or non-contracted entities
- Responsible for the daily operational activities which will ensure successful and accurate claims and capitation payment to various contracted or non-contracted entities
- All updates are to be made with a high degree of accuracy and speed
- Update and maintain Vendor Contracts; custom fee schedules and capitation agreements based on contract terms
- Assign the appropriate fee schedules to providers including writing and determining hierarchy of conditions and exceptions to the primary fee schedule based on the terms of the provider’s contract
- Manage and resolve timely claim queues for Provider edits (PVA - Pend Vendor Add) or Fee Schedule/rate inquiries (PFS - Pend Fee Schedule) by making appropriate updates in IDX
- Manage and resolve timely Change Forms received from Provider Contracting for new or amended contracts by making appropriate updates in IDX
- Assist in completion of major projects
- Define, develop, drive and deliver assigned small projects
- Assist with training new hires.
Medical Claims Examiner
Insight Global Temporary Agency/MemorialCare Medical Foundation
Fountain Valley, CA
10.2018 - 03.2020
- Adjudication of Commercial and Medicare Advantage Claims Documents resolution of claims to support claims payment and or decision
- Ability to identify and report processing inaccuracies that are related to system configuration
- Reviews processes and adjudicates claims for payment accuracy or denial of payment according to the Department’s policy and procedures
- Process all claims accurately conforming to quality and production standards and specification in a timely manner
- Ability to prioritize multitask and manage claims assignment with department goals and regulatory compliance and with minimal supervision
- Ability to make phone calls to Provider/Billing Offices, when necessary, based on department guidelines
- Requests additional information or follow up with provider for incomplete or unclean claims
- Determines out-of-network and out-of-area services providers and processes in accordance with company and governmental guidelines
- Assist in Customer Service
Medical Biller / Coder
Manuel F Mendoza Medical Office/Externship
Paramount, CA
07.2018 - 08.2018
- Code records by following prescribed coding standards such as ICD-9 and CPT Review physician notes and obtain necessary clarifications where necessary
- Ensure signatures on all medical records
- Assign appropriate medical codes to all diagnosis and services
- Prepare appropriate claim documents CMS1500 forms, Follow up with insurance companies and ensure that all claims are paid
- Post payments Researched paid or rejected claims through office ally.
Claims Examiner III
Career Strategies Inc/Director Guild of America PPHP
Los Angeles, CA
04.2017 - 08.2017
- Processing professional and hospital claims in the Vi-tech system
- Determine eligibility, medical necessity, reasonable and customary allowances, and appropriate coding
- Review policy booklet, medical reference books, and insurance company guidelines Investigate and adjudicate complex claim requests and claims requiring special handling
- Researched on pending claims
- Work with the Eligibility Department to resolve eligibility issues.
Business Analyst / Claims Examiner
HealthCare Partners Medical Group
El Segundo, CA
10.2000 - 09.2016
MemorialCareMemorialCareHoag
- Complete and/or screen preliminary data entry form for correctness of information QA and Tester Prepared or participated in the QA test planning, test creation, test case execution
- Required information efforts for application development projects
- Strong interpersonal skills and team skills Worked with shifting priorities
- Strong critical thinking, problem solving, decision making and analytical skills
- Ability to learn and understand all aspects of the business process
- Proficient with Microsoft Office Word, Excel, Outlook) Strong communication skills Verified and tested Medicare fee schedule and Benefits Gathering and analysis of business requirements in support of claims
- Responsible for working with other departments within the company
- Gathering document requirements specifications according to standard templates using simple, clear, unambiguous, and concise language
- Conduct analysis of complex stakeholder requirements; instantized requirements across departments
- Collaborated with MCA team to develop an approach that meets the stakeholder requirements
- Document detailed User Acceptance Test Scenarios to support testing of business requirements
- Assist with executive level documentation of cost/benefit analysis for function and scope decisions
- Ability to gather business requirements and work with key stakeholders
- Familiarity with claims data acquisition for testing scenarios/test cases.
Education
Medical Billing/Coder Diploma -
Downey Adult School Career and Education Center
08.2018
B.A. Degree Theology -
Step Out on Faith School of Ministry
12.2017
A.A. Degree -
Compton Community College
06.1990
Skills
- Medical Terminology; ICD-10-CM, CPT, HCPC, BLS, Insurance Compliance, CMS-1500 Claim Form and UB92, Medisoft, EHR’S, Microsoft office, Anatomy, types 35 wpm, Maces, IDX, and VI-Tech system, Customer Services, EMR/Adaptamed, EPIC, Equian, Client Matrix, Provider Matrix, Library, ProPac Due Date Calculator, Clinical Point, Outlook, Excel, Meditrac, Printers
- Analytical and Critical Thinking
- Microsoft Word
- Active Listening
- Friendly, Positive Attitude
- Critical Thinking
- Teamwork and Collaboration
- Dependable and Responsible
- Organization and Time Management
- Time Management
Timeline
Medical Claim Examiner
Kore1 Temp Agency/MemorialCare Medical Foundation
06.2023 - Current
Claims Payment Specialist
Liberty Dental Plan
04.2023 - 06.2023
Medical Claim Analyst
HealthCare Support/Optum Health Care
09.2021 - 08.2022
Medical Claim Examiner
The Judge Group/ Hoag Memorial Hospital Presbyterian
12.2020 - 07.2021
Provider Configuration Analyst
Vincent Benjamin Temp Agency/Prospect Medical Group
05.2020 - 10.2020
Medical Claims Examiner
Insight Global Temporary Agency/MemorialCare Medical Foundation
10.2018 - 03.2020
Medical Biller / Coder
Manuel F Mendoza Medical Office/Externship
07.2018 - 08.2018
Claims Examiner III
Career Strategies Inc/Director Guild of America PPHP
04.2017 - 08.2017
Business Analyst / Claims Examiner
HealthCare Partners Medical Group
10.2000 - 09.2016
Medical Billing/Coder Diploma -
Downey Adult School Career and Education Center
B.A. Degree Theology -
Step Out on Faith School of Ministry
A.A. Degree -
Compton Community College
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