Valerie Archuleta
Albuquerque,NM
Summary
I have great pride in my tasks and work ethics and delivering in a timely manner and using past experiences to convey on future problems to create better solutions.
I am also a highly motivated person to extrovert who commonly asks questions about current/future obstacles and fully supports a teamwork foundation with courageous individual thinking to challenge the possibilities.
Overview
20
20
years of professional experience
Work History
Appeals Specialist II
Blue Cross and Blue Shield of New Mexico
12.2019 - Current
- Collaborated with cross-functional teams to gather necessary documentation and evidence to support the appeals process.
- Managed high-stress situations with professionalism, ensuring that appeals were handled promptly and accurately even under tight deadlines or heavy caseloads.
- Consistently met or exceeded performance metrics, demonstrating a strong understanding of the claims review process and an unwavering commitment to achieving positive results for providers and members.
- Achieved successful appeal outcomes by meticulously reviewing and analyzing claim denials.
- Adjudicate appeals for Medicaid and Medicare, following federal and state guidelines.
- Educated members on their rights and responsibilities throughout the appeals process, ensuring a clear understanding of expectations and potential outcomes.
Customer Advocate Quality Coach
Blue Cross and Blue Shield of New Mexico
02.2006 - 12.2019
- Conduct audit on Customer Advocates to ensure each inquiry is handled appropriately.
- Provide written and verbal face to face feedback as well as coaching to individuals on findings.
- Enter data into EPPS and produce individual Performance Reports as requested.
- Recommend improvements in processing and procedures by informing appropriate personnel of revisions.
- Supported phones when needed.
Claims Quality Auditor
Blue Cross and Blue Shield of New Mexico
09.2004 - 01.2006
- Enhanced claims processing accuracy by conducting thorough quality audits and providing feedback to claims processors and examiners.
- Mentored new auditors on company policies and procedures while fostering a positive work environment conducive to learning.
- Audit Blue Card Host, Medicaid, and New Mexico Business processors and examiners through the EPPS program.
- Review rebuttals, and manual calculations
- Audit and release prepays for all products
Education
High School Diploma -
Valley High School
Albuquerque, NM05.1995
Skills
- HIPAA Compliance Knowledge
- Professionalism and Ethics
- Continuous learning mindset
- Organizational abilities
- Problem solving and critical thinker
- Ability to work independently and collaborations
- 10-key
- Strong analytical skills
- Customer Service
- Attention to Detail
- Multitasking Abilities
- Reliability
Timeline
Appeals Specialist II
Blue Cross and Blue Shield of New Mexico
12.2019 - Current
Customer Advocate Quality Coach
Blue Cross and Blue Shield of New Mexico
02.2006 - 12.2019
Claims Quality Auditor
Blue Cross and Blue Shield of New Mexico
09.2004 - 01.2006
High School Diploma -
Valley High School
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