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CQI Auditor Resume Example

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CQI AUDITOR
Professional Summary
Seeking a full-time position in the southern California area as an experienced medical claims examiner/adjuster and/or auditor, where I can utilize my knowledge of analytical, clerical, and administrative skills within the healthcare field.
Skill Highlights
Over 10 years' experience in claims adjudication; Medical Terminology; CPT/ICD-9, ICD-10 and HCPCS coding; CMS 1500 (professional) and UB04 (hospital) Inpatient; Data Entry; DRG pricing; Patient Scheduling; Problem Solving; Phone Skills; MediSoft (minor); Medical Manager; Lytec; Typing (46 wpm) and Ten-key (11,940 kph); Excel, Microsoft Word; Windows Versions '95 through 10; Lotus Notes 6.54, Internet Explorer 11; PPO, HMO, EPO, Indemnity products for California and Arizona
Professional Experience
January 2013 to May 2016
Health Net, Inc. of CaliforniaRancho Cordova, CACQI Auditor
  • Researches/adjusts all difficult, complex requests for overpayment, underpayment, refund, and contract issues to ensure compliance with departmental and company policies and procedures.
  • Identified performance trends/patterns of audits to management, and makes recommendations to improve quality, workflow processes, policies and procedures.
  • Researched claim processing problems and errors to determine their origin and provides appropriate feedback to examiners, trainers and management.
  • Helps to evaluate the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.
  • Processes all adjustment issues, as they occur to comply with company service standards and to ensure achievement of company goals.
  • Provided coaching and feedback to examiners and management on prepayment and post payment findings and trends.
  • Monitors daily assignments and prioritizes aged audits to ensure all audits are completed timely per regulatory and department guidelines.
  • Maintains/updates knowledge of all claims products, contracts and standard reference materials.
  • Claims re-adjudication, vendor contract review, application of benefits & copay, COB benefits.
  • Ensures compliance with government regulations and requirements (NCQA, DOC, DHCS,HCFA).
  • Performs special projects as assigned.
August 2009 to December 2012
Correct Care Integrated HealthSacramento, CAClaims Processor
  • Processed medical insurance claims for state prison inmates.
  • Mailing and batching.
September 2008 to August 2009
Health Net, Inc. of CaliforniaRancho Cordova, CAClaims Adjuster I
  • Researched / adjusted requests of PPO and minor HMO claims for overpayment, underpayment, refund and contract issues to ensure compliance with departmental and company policies and procedures.
  • Conducted cost containment analyzes.
  • Determined level of reimbursement based on established criteria: contracts, plans, and employer groups.
  • Coordinated special payment agreements with providers based on contract terms.
  • Maintained / updated knowledge of all claims products, contracts and standard reference materials.
  • Adjusted claims for re-pricing through web vendors (i.e.
  • Multiplan, Beechstreet, National Care Network and First Health network.) Performed special projects as assigned.
November 2005 to September 2008
Health Net, Inc. of CaliforniaRancho Cordova, CAClaims Examiner II- OPS
  • Processed all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specification in a timely manner.
  • Experienced with claims procedures, rules & guidelines, and all aspects of claims adjudication (ex.
  • COB rules, multiple surgeries, lab/radiology, etc.) Processed both professional (CMS-1500) and institutional (UB04) claims for PPO and IFP PPO products, including new day claims, online web pricing, adjustments and repers.
  • Processed claims for re-pricing through web vendors (i.e.
  • Multiplan, Beechstreet, and Medavant (Plan Vista), National Care Network and Fee Negotiations unit.) Trained individuals at vendor re-pricing.
  • Documented provider claims/billing forms to support payment/decisions.
  • Matched authorizations to claims, maintains current desk procedural and online/offline reference materials.
  • Reviewed appeals and complaints; researches any missing or required information.
  • Processed and/or reprocessed claims for adjustment regarding incorrect information.
  • Produced a substantial amount of claims per day, exceeding in range of 95 to 230 claims, based on production standards.
  • Provided single-handed training to individuals on various duties including: adjustments, vendor pricing, and specific claims processing areas.
February 2005 to April 2005
Creekside Chiropractic and Physical TherapyElk grove, CAMedical Biller- Externship
  • Assisted with medical billing, medical records, and accounts receivable/payable.
  • Verified patient health care insurance for Medicare, MediCal, and Workers' Comp.
  • Performed clerical duties for front office, and operated general office equipment.
April 2001 to September 2001
Jenny Craig Weight LossSan Jose, CAConsultant
  • Scheduled weekly patient visits.
  • Sold promotional products; invoicing and cashiering.
  • Distributed and explained information.
September 2000 to November 2000
Stanford Health and ClinicsPalo Alto, CAData Entry Processor
  • Entered and processed information on HCFA-1500.
  • Updated patient information.
June 2000 to September 2000
EDS Manpower StaffingSan Jose, CAHealth Insurance Claims
  • Edited and processed information on TARs.
  • Compiled and organized documents in preparation for mailing and batching.
  • Organized filing system.
Education and Training
Jan 2006
Health Net, Inc
Gold River, CA, USA
Certificate of CompletionCompleted the training requirements for newly hired associates. Completed the training requirements for facility/institutional processing.
Jun 2005
Carrington College (formerly Western Career College)
Sacramento , CAMedical Billing
Associate of ScienceGPA: Graduated with an AS degree for medical billing. Received a certificate of typing/ten-key proficiency; Volunteer Excellence Award for student mentoring.
Jan 2001
Metropolitan Adult Education
San Jose, CA, USAMedical Billing
Certificate of CompletionGPA: GPA: 3.4Graduated
Skills
Ten-key, accounts receivable, benefits, billing, cashiering, clerical, CMS, coaching, contracts, contract review, CPT, Data Entry, filing, forms, front office, general office, government regulations, ICD-10, ICD-9, insurance, Internet Explorer, invoicing, Lotus Notes 6.54, Mailing, materials, medical billing, Medical Manager, Medical Terminology, MediSoft, Excel, Windows, Microsoft Word, Monitors, Negotiations, Network, policies, pricing, Problem Solving, Processes, coding, quality, radiology, Scheduling, specification, Phone Skills, Typing, Vista, workflow
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Resume Overview

Companies Worked For:

  • Health Net, Inc. of California
  • Correct Care Integrated Health
  • Creekside Chiropractic and Physical Therapy
  • Jenny Craig Weight Loss
  • Stanford Health and Clinics
  • EDS Manpower Staffing

School Attended

  • Health Net, Inc
  • Carrington College (formerly Western Career College)
  • Metropolitan Adult Education

Job Titles Held:

  • CQI Auditor
  • Claims Processor
  • Claims Adjuster I
  • Claims Examiner II- OPS
  • Medical Biller- Externship
  • Consultant
  • Data Entry Processor
  • Health Insurance Claims

Degrees

  • Certificate of Completion
    Medical Billing Associate of Science
    Medical Billing Certificate of Completion

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