WERONIKA CARRETO
Tolleson,AZ
Summary
Organized and detail-oriented team lead with 10+ years of dental and vision claims experience dedicated to improving efficiency, productivity and profitability through continuous process improvement. Analytical thinker skilled at developing innovative solutions to complex problems.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Vision Claims Lead
Avesis
Phoenix, AZ
01.2022 - Current
- Monitored team performance and provide regular feedback to ensure continuous improvement
- Conducted regular one on one sessions as well as new hire training classes
- Ran and assigned daily inventory to ensure SLA and TAT is met according to plan and state guidelines
- Created SOP guides for the department training material and processes
- Assisted with complex claims processing and inquires
- Analyzed and collected claims data and reported findings to management
- Worked with other departments when claims issues occurred to ensure correct claims processing
- Performed various claim audits
- Worked with vision consultants on medical claim reviews OK see
Interim Claims Supervisor
Avesis
Phoenix, AZ
12.2022 - 04.2023
- Assisted in the recruitment and selection of new claims adjusters, ensuring they possessed the necessary skills and expertise to excel in their roles.
- Optimized workflow efficiency through system enhancements and trend findings to reduce inventory and company cost
- Monitored performance metrics regularly, identifying areas for improvement and implementing corrective measures accordingly.
- Fostered a positive work environment that promoted collaboration, teamwork, and open communication among team.
- Maintained up-to-date knowledge on claims processes, best practice and regulatory changes to ensure optimal decision-making in the claims management process.
Utilization Review Senior Processor
Avesis
Phoenix, AZ, USA
10.2020 - 12.2022
- Assisted management with daily operations of the Utilization Review department
- Monitored and assigned daily inventory to ensure timely and accurate processing of dental authorizations
- Performed daily audits and error reports
- Reviewed others' work outputs and provide input to manager on employee performance
- Assisted admin team by taking on additional administrative duties including letter creation and review
- Proficient in processing all of Avesis dental plans including orthodontic codes
- Assisted in the implantation of a BOT to enhance authorization attachment process
- Written Job Aids, SOPs and successfully trained team mates
- In addition to newly assigned tasks still exceeded productivity and quality goals monthly
Utilization Review Processor
Avesis
Phoenix, AZ, USA
05.2017 - 10.2020
- Conducted review of pre-treatment requests submitted by providers for dental services for major Medicare and Medicare plans
- Proficient in reading x-rays for medical need and able to determine when to refer to a Dental Consultant
- Finalized authorizations in a timely manner to ensure turnaround and accuracy without missing deadlines
- Performed review of orthodontic authorizations including continuation of care requests and Commission for Children
- Assisted the supervisor with any additional duties including creating SOPs and providing training to other team mates
- Assisted in and completed audits
- Exceeded quality and production goals on a monthly basis
Dental Claims Processor
Avesis
Phoenix, AZ, USA
02.2014 - 05.2017
- Processed dental claims using Avesis systems and applications
- Knowledgeable in diagnosis and procedural coding
- Proficient in majority of Medicaid And Medicare dental plans, including corrective claims and projects for orthodontic claims
- Maintained a steady accuracy and quality performance, often exceeded productivity goals
Customer Service Representative
General Dynamics
Scottsdale, AZ, USA
08.2011 - 08.2013
- Managed over 50 inbound customer calls for 1-800-MEDICARE on a daily basis
- Assisted beneficiaries regarding Medicare policies, procedures, payments and limited income programs
- Assisted with claims, research, denials, and appeals as well as filling BIU Fraud investigations to Medicare contractors
- Completed enrollments into Medicare Part C Advantage and Medicare Part D Prescription drug plans
- Assisted with training new employees
- Lead CSR during the nesting program
Education
Associate of Science - Dental Assisting
The Bryman School of Arizona
Phoenix, AZ01.2012
High School Diploma -
Washington High School
Phoenix, AZ01.2009
Skills
- MS Office
- Self-starter
- Self-motivator
- Dependable
- Adaptable
- Flexible
- Multitasking
- Organization
- Claims review
- Vision insurance
- Dental insurance
Certification
Certified Dental Assistant
Languages
Polish
Native or Bilingual
Timeline
Interim Claims Supervisor
Avesis
12.2022 - 04.2023
Vision Claims Lead
Avesis
01.2022 - Current
Utilization Review Senior Processor
Avesis
10.2020 - 12.2022
Utilization Review Processor
Avesis
05.2017 - 10.2020
Dental Claims Processor
Avesis
02.2014 - 05.2017
Customer Service Representative
General Dynamics
08.2011 - 08.2013
Associate of Science - Dental Assisting
The Bryman School of Arizona
High School Diploma -
Washington High School