Eli's Folder 2
- 1. ELIZABETH DIAZ Beltsville, MD Elizdiaz77@yahoo.com 240-432-8747 OBJECTIVE To obtain a Challenging position in the Medical field utilizing my knowledge and skills in the Areas of medical Claims Audits, Medical office policies, and reimbursement specialist procedures. EXPERIENCE: SENIOR CLAIMS AUDITOR- Trusted Health Plans- August 2013- Present . Perform comprehensive review of medical records for documentation consistency and accurate use of ICD-9, ICD-10 and CPT codes . Evaluate Claims for Vendors, and recommend required course of action for resolution. Interface with Organization personnel to include fellow team members, supervisor, managers and customers and maintain the integrity of Claims. . Performs vendors Claims research for customers to reach resolution. . Identify, validate, and document moderate to more complex audit projects . Assist the Claims Manager with resolving difficult problems and handling escalating unresolved problems. . Generate weekly and monthly Audit reports. . Complete monthly Reimbursement reports in accordance with deadlines set by supervisor. . Conduct Reinsurance Claims Research and prepare monthly report. . Updates job knowledge by participating in educational opportunities. . Enhances organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments. . Execute more independent auditing projects as assigned by the Claim Department Manager . Navigate in the claims processing system to determine various aspects of the claim detail which contributes to clean claim adjudication.
- 2. . Research and provide resolution for departmental claim inquiries by completing daily Accounts Payable Audits . Identifies data for claim liens and corresponds with law office(s) for legal medical claims and provide detailed account analysis . Trains all new employees on the claims processing system, policies/procedures, and all other areas needed to effectively complete their workflows . Research Provider Contracts for payment accuracy BILINGUAL CUSTOMER SERVICE REPRESENTATIVE- Pepco Holdings- July 2008-August 2013 -Answer phone inquiries in a timely manner and provide quality service to commercial and residential customers in both English and Spanish. Analyze and review accounts sufficiently to resolve complaints and issues. -Assist customers with payment arrangement. -Take accurate information from customers to transfer, initiate and cancel service. -Keep customers up to date with rates. -Demonstrate skill using a basic PC-based word processing, spreadsheet, Data base and email software. -Inform customer of account status, billing inquiries, and payment options. Communicate orally and in writing with internal and external customers. MEMBER SERVICES REPRESENTATIVE- Chartered Health Plan- November, 2006-July, 2008 · Informing and educating plan members on how to properly use the medical service available to them. · Handling member problems or making necessary referral for appropriate resolution. · Update daily ACD Phone status report, and forward to Supervisor. · Create Certificate of coverage per Health Care Providers and Members request, and update Prescription Plan. · Responsible for documenting all interactions with members and forward that information to the appropriate person for follow-up. · Utilized knowledge of medical terminology, claim adjudication and general benefit plan. · Assist over 50 customers daily simultaneously, over the phone and in Person at times. · Handling telephone inquiries from members, and Health Care Providers regarding benefits, claim status, eligibility, and reimbursement for the
- 3. various Product. · Assist, prepare, and process new member packages and cards. · Provide service sensitive to customer satisfaction such as updating member information and entering account comments and warning. · Update job knowledge by participating in educational opportunities. · Knowledge of Medicaid and Alliance HMO. · Provide Bilingual support (Spanish to English) to members. · Print member cards. MEDICAL OFFICE ASSISTANT-Urologic Surgeons of Washington- August, 2005-October, 2006 · Handle busy front desk. · Verify Insurance information. · Register and Schedule patients to assigned Doctors. · Enter office visit charges. · Collect co-payments. · Pre-cert and Schedule procedures and surgeries. · Assist in the billing process. · Scan and enter Patients demographics. · Handle very busy phone system. · Knowledge of Medical Terminology. · Experience in Managed Care Health plan, HMO, and PPO Plan. · Knowledge of Referrals, and Treatment Plans. EDUCATION BETHESDA CHEVY CHASE HIGH SCHOOL- Bethesda MD- June, 1995 Diploma SKILLS: Fluent in Spanish Micrsoft Office, Micrsoft Outlook, Medical Terminology, Medical Manager, Word, Excel, MHC, CareConnect, RadMD GROUPS: AAPC
- 4. June 2015-Present REFERENCES Available upon request.