Yesenia Perez Paez
Fresno,CA
Summary
Experienced professional with a strong background in customer service and training seeking a responsible career opportunity. Proven ability to excel under pressure in fast-paced environments and effectively prioritize work. Adaptable to change and dedicated to delivering exceptional results. Possess strong organizational skills and proficiency in multiple software programs. Qualified Claims Representative versed in investigating claims, verifying information and managing settlements. Friendly and upbeat team player with organized and disciplined approach. Offering 4 years of insurance experience. Analytical problem-solver with excellent communication skills. Effective at interviewing claimants, compiling records and documenting findings. Well-versed in insurance policies, practices and standards.
Overview
6
6
years of professional experience
1
1
Certification
Work History
Insurance Claims Specialist
PFS Group
12.2024 - Current
- Process claims for different specialties such as cardiology, urology, dental, opthalmology, gastrology, dermatology, OB-GYN, surgeries, and other medical DX.
- Call different insurances to confirm authorizations have been approved after creating them with the proper provider and attaching medical records.
- Use Epic, Excel, Word, Microsoft Office, Teams., and etc. In order to properly attend meeting as well as follow protocol with up to date insurance policies.
- Minimized errors in claims submissions through regular cross-checking of CPT and ICD codes against medical documentation.
- Collaborated with medical staff to obtain necessary documentation, enabling timely submission of accurate claims.
- Assisted colleagues during peak workload periods, demonstrating strong teamwork and commitment to overall departmental success.
- Stayed up-to-date with industry developments and changes in insurance policies to ensure ongoing compliance and adaptability in billing practices.
- Maintained strong working relationships with insurance providers, fostering open communication channels for claim resolution.
- Maintained up-to-date knowledge of insurance policies and changes, ensuring accurate billing practices.
- Used data entry skills to accurately document and input statements.
- Entered invoices requiring payment and disbursed amounts via check, electronic transfer or bank draft.
Claims Representative
Cigna
11.2022 - 08.2024
- Review claim submissions to confirm required documents have been received, verify medical codes, eligibility, other insurance, authorizations, and account benefit plans
- Follows established policies and procedures to pay, pend for additional information, or deny claims
- Adapt to and positively influence change by accepting feedback with a growth mindset to continuously improve
- Follow processes and work independently to meet or exceed Key Performance Indicators (KPI) Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1x1 or check-ins, using a variety of virtual tools, i.e
- Outlook email, Skype for Business, Cisco Web-Ex, or other similar applications
- Maintains a high level of accuracy in all duties performed
- Team members will be held accountable for meeting and maintaining minimum quality and production standards through use of Management Operating Systems (MOS) tools: Daily Production Log (DPL), Performance Profile, Claim Review tool, and other reporting systems
- Partner with the Resource Management Group (RMG) on Workflow Tool (WFT), pended claims, or other inventory issues
- Partner with Technical Coaches to understand claim processes and procedures.
- Worked effectively in fast-paced environments.
- Self-motivated, with a strong sense of personal responsibility.
- Learned and adapted quickly to new technology and software applications.
- Strengthened communication skills through regular interactions with others.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
- Paid attention to detail while completing assignments.
- Organized and detail-oriented with a strong work ethic.
- Managed time efficiently in order to complete all tasks within deadlines.
- Assisted with day-to-day operations, working efficiently and productively with all team members.
Medical Records Clerk/ Scanner
Castle Family Health Center
12.2020 - 05.2022
- Scanned over 400 documents per day, organized, and access electronic health records
- Help the front desk with patients, answered 30 phone calls, filed 30 patient’s charts, look for patient’s charts, and offer to help others in scanning
- Familiar with medical terminology
- Attention to detail to ensure accuracy of information that is being put in is correctly
- Also help to scan 40 radiology, valley children’s documents, and 50 labs making sure to send them to the correct provider to be signed electronically.
- Maintained confidentiality of all medical records and sensitive information to comply with HIPAA regulations.
- Scanned medical records in digital format for easy retrieval and accessibility.
- Assisted in preparation of medical records to release to other medical facilities requesting for patient history and information.
- Uploaded physician progress notes, history, and physicals into electronic medical records.
Care Manager/ Gero-Psych & Medical Detox
Good Samaritan Hospital
04.2019 - 08.2019
- Direct contact with patients in psychiatric and medical units
- Interacted with patients diagnosed with various mental illnesses and developmental delays.
- Assisted clients with daily living needs to maintain self-esteem and general wellness.
- Provided crisis intervention services when necessary by assessing risk levels promptly addressing safety concerns collaboratively with the treatment team.
- Communicated with healthcare providers to facilitate continuity of care.
- Participated in team meetings and trainings to stay updated on best practices and new developments in care management.
- Coordinated referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services for patients.
- Responded to emergency situations and provided support to promote client safety and wellbeing.
- Improved patient satisfaction through effective communication and collaboration with interdisciplinary healthcare teams.
- Conducted risk assessments for patients, proactively addressing potential health issues.
- Conducted comprehensive assessments to identify patient needs, facilitating targeted support.
- Developed and updated policies and procedures, maintaining compliance with guidelines relating to HIPAA, benefits administration and general liability.
- Designed and introduced leadership development, coaching and team management model, resulting in promotion of employees into increased levels of responsibility.
- Arranged transportation and documented details of discharge transition plans.
- Maintained detailed records in compliance with agency standards and regulations.
Education
Bachelor of Science - Business Administration And Management
Southern New Hampshire University
Hooksett, NH08.2025
UC Berkeley Executive Strengthening Self Advocacy - Business Management
UC Berkely
09.2023
Associate of Science - Business Administration And Technology
Taft College
Taft, CA05.2022
CPR/AED Certified -
National CPR Foundation
05.2022
Typing Speed 65 WPM And Proficiency Test -
Bakersfield Adult Schools
Bakersfield, CA01.2019
Skills
- Microsoft Office
- Insurance Claims Review
- Claims Investigation
- Time Management
- Team Collaboration
- Data Analysis
- Decision-Making
- Interpersonal Communication
- Coverage assessments
- Coverage Determination
- Task Prioritization
- Analytical Thinking
- Excellent Communication
- Organizational Skills
- Skilled in MOS, DPL CPF, CED, BLUEZONE, PMHS, MACRO, Microsoft Office, Excel, Proclaim, Powerpoint, Notepad, Webex, and Oracle
- Teamwork and collaboration
- Policy interpretation
- Claims analysis
- Claims investigation
Certification
- Strenghthing Self-Advocacy Experience - UC Berkeley Executive Education- Sep 02, 2023
Languages
English
Native or Bilingual
Spanish
Native or Bilingual
Education
true
References
- Carlos Mendoza, (209) 704-4107
- Veronica Pacheco, (209) 777-4417
Timeline
Insurance Claims Specialist
PFS Group
12.2024 - Current
Claims Representative
Cigna
11.2022 - 08.2024
Medical Records Clerk/ Scanner
Castle Family Health Center
12.2020 - 05.2022
Care Manager/ Gero-Psych & Medical Detox
Good Samaritan Hospital
04.2019 - 08.2019
UC Berkeley Executive Strengthening Self Advocacy - Business Management
UC Berkely
Associate of Science - Business Administration And Technology
Taft College
CPR/AED Certified -
National CPR Foundation
Typing Speed 65 WPM And Proficiency Test -
Bakersfield Adult Schools
Bachelor of Science - Business Administration And Management
Southern New Hampshire University
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