Vilma miranda
Las Vegas,NM
Summary
Results-driven Claims Processing Specialist with Cigna Allegiances Medical Group, skilled in claims review and regulatory compliance. Proven ability to enhance efficiency and customer satisfaction through process improvements and effective communication. Adept at utilizing claims processing software and fostering team development, ensuring accurate and timely resolution of complex cases.
Overview
11
11
years of professional experience
Work History
Claims Processing Specialist
Cigna Allegiances Medical Group
Las Vegas
01.2018 - Current
- Executed thorough processing and review of claims to ensure accuracy and compliance with company policies.
- Utilized claims processing software to efficiently manage documentation and workflow.
- Collaborated with healthcare providers to resolve claim discrepancies and streamline communication.
- Analyzed claims data to identify trends and recommend process improvements.
Grievance Appeals Specialist
Molina Health Care
Los Angeles, CA
06.2015 - 12.2017
- Analyzed grievance appeals to ensure compliance with regulatory standards and company policies.
- Coordinated resolution processes, collaborating cross-functionally with various departments to address member concerns.
- Reviewed and assessed documentation to determine case validity and appropriate course of action.
- Developed training materials for staff on grievance procedures and best practices for handling appeals.
- Implemented process improvements that enhanced efficiency in handling appeal cases and reduced turnaround time.
- Mentored junior specialists, providing guidance on complex cases and fostering skill development within the team.
- Assisted in policy development by providing expert insights based on experience handling complex grievances and appeals cases.
- Enhanced grievance appeals efficiency by streamlining processes and implementing best practices.
- Improved customer satisfaction rates by providing timely and empathetic responses to appeals inquiries.
- Resolved escalated cases promptly and effectively, demonstrating strong negotiation skills when liaising with stakeholders.
Education
Associate of Science - Buissness Administration
Chaffey College
Rancho Cucamonga, CA12.2002
Skills
- Claims processing software
- Verbal communication
- Medical terminology
- Data entry proficiency
- Claims review
- Insurance regulations
- Claims
- Policy interpretation
- Regulatory compliance
- Allocating claims
- Customer service
- Problem-solving
- Time management
- Attention to detail
- Multitasking
- Claims investigation
- Documentation skills
Timeline
Claims Processing Specialist
Cigna Allegiances Medical Group
01.2018 - Current
Grievance Appeals Specialist
Molina Health Care
06.2015 - 12.2017
Associate of Science - Buissness Administration
Chaffey College