Valerie Padilla
Fruita
Summary
Over 20 years in health care operations. A dedicated professional with years of experience in analyzing and mapping HMO benefits, contracts, and provider demographics in an HMO managed care system. Thorough understanding of the claims adjudication process, contractual division of financial responsibility, provider contract verbiage and all aspects of coding, i.e., CPT, ICD10, HCPC, Revenue coding, DRG, APC, RBRVS.
Dependable office management professional brings many years of experience in administrative oversight. Self-starter and skilled team leader with history unifying staff under common goals, modeling organizational efficiency, and instilling customer service excellence.
Overview
27
27
years of professional experience
1988
1988
years of post-secondary education
Work History
Office Manager
Western Slope Orthotics, Inc
Grand Junction
08.2017 - Current
- Manage daily operations to include scheduling appointments, handling of all incoming Health Plan correspondence such as non payment and appeals, Billing to all Government agencies/Health Plans, Post Payments, Ordering/tracking of orthotic/bracing form our contracted Vendors.
System Configuration - Telecommute (contract)
MV Medical Management
Los Angeles
08.2016 - 02.2017
- Build division of financial responsibility to ensure misrouted claims are processed correctly
- Research/troubleshoot system claims related issues and provide feedback to Management.
Claims Manager
MV Medical Management
11.2013 - 08.2016
- Manage staff of Auditors and Claims Examiners
- Knowledge of professional and institutional claims processing for Medicare,Medi-cal and Commercial lines of business
- Knowledge of Medicare,Medi-cal and Commercial reimbursement to include DRG, APC, RBRVS, and Stoploss
- Responsible for oversight of the Claims Customer Service Unit
- Establish Policy & Procedures for new claims processes
- Monitor and delegate work as necessary
- Assist with Health Plan and/or CMS audits to ensure compliance standards are met according to regulatory guidelines
- Familiarity with 5010 requirements for HCC reporting
- Train Terms & Conditions unit with system set-up to ensure benefits are applied to each claim.
- Troubleshoot areas of improvement to ensure accurate claims processing and reimbursement
- Provide updates to the Senior Management on areas of improvement as it relates to claims processes
Claims Manager
Healthsource MSO
Alhambra
12.2010 - 06.2013
- Manage staff which consist of Supervisor, Auditors, Claims Examiners and oversight of offshore Claims processing
- Knowledge of professional and institutional claims processing for Medicare,Medi-cal and Commercial lines of business
- Knowledge of Medicare,Medi-cal and Commercial reimbursement to include DRG, APC, RBRVS, CMAC, and Stoploss
- Responsible for development of the Claims Customer Service Unit
- Establish Policy & Procedures for new claims processes
- Monitor and delegate work as necessary
- Attend Joint Operations Committee (JOC) meetings to improve claims adjudication and payments
- Oversee internal claims auditors to ensure accurate and timely processing of all claim types
- Assist with Health Plan and/or CMS audits to ensure compliance standards are met according to regulatory guidelines
- Familiarity with 5010 requirements for HCC reporting
- Train Terms & Conditions unit with system set-up to ensure benefits are applied to each claim.
- Participate in monthly conference calls to resolve any claims related issues with Providers
- Troubleshoot areas of improvement to ensure accurate claims processing and reimbursement
- Attend necessary seminars to keep apprised with State and Federal regulations
- Provide updates to the Senior Management on areas of improvement as it relates to claims processes
Manager of Network Support Services
Citizens Choice HealthPlan
Cerritos
08.2009 - 12.2010
- Network Support Manager managing staff of 3 employees
- Responsible for all automation and system maintenance as it relates to claims processing.
- Configure Health plan benefit structure to improve benefit adjudication
- Configure co-pays, deductibles, co-insurance in the Ezcap system.
- Configure fee schedules according to contract verbiage to ensure proper claims payment.
- Configure DOFR s to ensure shared/full risk services are properly adjudicated.
- Provide feedback to the Claims department of any regulatory changes as it relates to pricing
- Establish policy and procedures within the department
- Responsible for obtaining all fee schedule updates on an annual, quarterly basis from CMS, Noridian, Palmetto
- Responsible for ensuring all fee schedule updates have been implemented in the Ezcap system
Claims Manager
Citizens Choice HealthPlan
Cerritos
05.2006 - 08.2009
- Claims Manager managing staff of 8 employees
- Extensive knowledge of professional and institutional claims processing
- Responsible for development of the Claims Department
- Establish Policy & Procedures for claims processing
- Monitor and analyze claims unit for performance
- Worked closely with various department and attend committee meetings to improve claims adjudication and payments
- Oversee internal claims auditors to ensure accurate and timely processing of all claim types
- Oversight of Health plan Coders
- Oversight of Health plan auditors
- Oversight of 31 contracted IPA s which are delegated for claims processing
- Conduct annual IPA audits to ensure compliance standards are met according to regulatory guidelines
- Providing feedback to the Delegation Oversight Committee of any issues or concerns with in an IPA.
- Responsible for oversight of all on-site claims audits conducted by CMS, HEDIS, DMHC
- Knowledge in working with claims Capitation Deductions, Stoploss, Shared/Full Risk, HCC/Encounter data reporting, DRG, HCPC, CPT, ICD-p, APC
- Provide staff with mentoring of day to day functions
- Attend necessary seminars to keep apprised with State and Federal regulations
- Provide quarterly updates to the Board of Directors as it relates to claims processes
- Implement Recovery Unit to capture all potential overpayments within the claims department
Customer Service/Terms & Condition Supervisor
CareMore Medical Management
Cerritos
01.2001 - 05.2006
- Supervised Customer Service staff of 5
- Responsible for monitoring the phone queue to ensure that proper feedback is provided and all calls are handled in a timely manner
- Provided feedback to Senior Management regarding issues that arise through the phone queues to assist in claims training
- Monitored phone queues through Desktop reporting
- Maintained policy and procedures within the department
- Supervised Terms & Condition staff of 5
- Responsible for all system maintenance within the claims processing system
- Configured Health plan benefit structure to improve benefit adjudication
- Ensure accurate input of applicable co-pays, deductibles, co-insurance and out-of-pocket expenses have been updated properly throughout the Ezcap system.
- Configured fee schedules according to contract to ensure proper claims payment.
- Configured Division of Financial Responsibility within the Ezcap system
- Responsible for ensuring all fee schedule updates have been implemented in the Ezcap system
- Handle all processing of PCP encounter data claims
- Prepared Stoploss reports to provide to Stoploss carrier
- Audited all Stoploss payments made by Stoploss carrier
- Oversight of Recovery Unit to ensure all recoveries were properly adjudicated
Office Manager
Ghassan K. Roumani, M.D.
Alhambra
09.2000 - 01.2001
- Supervised front and back office hires
- Prepared daily deposits
- Entered/Updated patient information in billing system
- Added/Modified Insurance, CPT codes, ICD-9 codes in billing system
- Audited superbills for any errors prior to billing
- Audited and mail claims for reimbursement
- Followed-up and collect on outstanding accounts
- Handled all billing inquiries from insurance companies and/or patients
- Coded surgeries and handle all paperwork given by Dr Roumani
Account Follow-up Manager
Pediatric Management Group
Hollywood
01.2000 - 09.2000
- Responsible for monitoring all commercial health plans to determine issues and payment trends
- Developed strategies to optimize results for each payer account
- Provided feedback to Contract Managers of any issues/problems with in a payer account
- Made analytical billing and collection decisions
- Successful in working with different payers to settle accounts to minimize A/R
- Provided oversight and training to correspondence team
Configuration Analyst/Provider Analyst
Huntington Provider Group
Pasadena
04.1999 - 01.2000
- Added new benefit packages, tiers, and abstracts into the AS400 system
- Input applicable co-pays, deductibles, co-insurance and out-of-pocket expenses
- Updated, changed and modified benefit packages when notices received. In addition will add, update and modify benefit packages to reflect plan organization division of responsibilities
- Responsible for Provider and Vendor Maintenance, contract interpretation and application of appropriate reimbursement methodologies
- Responsible for annual rate changes by CMS
Education
Fruita Monument High
Fruita, CoSkills
- Ezcap
- QuickCap
- 10-Key by touch
- Typing
- CRT
- Medical Terminology
- Microsoft Word
- Excel
References
Available upon request
Timeline
Office Manager
Western Slope Orthotics, Inc
08.2017 - Current
System Configuration - Telecommute (contract)
MV Medical Management
08.2016 - 02.2017
Claims Manager
MV Medical Management
11.2013 - 08.2016
Claims Manager
Healthsource MSO
12.2010 - 06.2013
Manager of Network Support Services
Citizens Choice HealthPlan
08.2009 - 12.2010
Claims Manager
Citizens Choice HealthPlan
05.2006 - 08.2009
Customer Service/Terms & Condition Supervisor
CareMore Medical Management
01.2001 - 05.2006
Office Manager
Ghassan K. Roumani, M.D.
09.2000 - 01.2001
Account Follow-up Manager
Pediatric Management Group
01.2000 - 09.2000
Configuration Analyst/Provider Analyst
Huntington Provider Group
04.1999 - 01.2000
Fruita Monument High