Nanette Arradaza

Medical Claims Examiner

September 2009 to May 2010

• Analyze and adjudicate claims from providers base on provider contractual agreement, health plan division of financial responsibility, claims processing guidelines and clients group and company policy and procedure.
• Analyze and adjudicate senior member claim base on HCFA's timeliness and accuracy regulations.
• Review services for appropriateness of charges and medical necessity and ensure that prior authorization and pre certification guidelines are applied during claims processing.
• Calculate and apply usual customary and reasonable rates on non-contracted provider.
• Telephone contact with providers to obtain additional data.
• Responsible in keeping up with pended claims in timely manner.

Personal Lines Assistant

October 2007 to May 2009

• Assist CSR's in Servicing insured with their insurance coverage.
• Prepare Binder and Evidence of Insurance
• Endorse any changes to insurance carrier.
• Mail out cancellation notice to insured.
• Make a courtesy call to insured when policy is about to cancel.
• Get a Motor Vehicle Records online when CSR's need it in preparing a quote.

Medical Claims Examiner

September 2006 to October 2007

• Assigned to different Insurance company for temporary position
• Work with All Temporary Inc Off and On depending on how long the assignment will last.
• Review and adjudicate medical claims base on provider and health plan contract agreement, claims processing guidelines and client's company policy and procedure.

Medical Claims Examiner

December 2005 to September 2006

CA.
Medical Claims Examiner
• Assigned to a specific school, to handle medical insurance of a student who have coverage with Personal Insurance Administrators.
• Received student files, check if student has a current coverage.
• Review student files, if claim is subject to pre-existing, request for claim form, medical records and prior coverage.
• If claim is not subject to pre-existing, check if claim is base on provider contractual agreement.
• Review service for appropriateness of charges and medical necessity and ensure that prior authorization and pre certification guidelines are applied during claims processing.

Medical Claims Examiner

February 2005 to August 2005

• Assigned to different Insurance companies for temporary position.
• Work Off and On depending on how long the assignment will last.
• Review and adjudicate provider claims base on provider and health plan contractual agreement.
• Respond to resolved provider and health plan claims inquiries and apply resolution in a timely fashion
• Maintain departmental standards on productivity and quality of work.

Medical Claims Examiner

July 2002 to January 2005

• Processed Medi-Cal, Senior and Commercial products for UHP. Work includes adjustment and appeals.
• Analyze and adjudicate claims from providers base on provider contractual agreement, health plan division of financial responsibility, Claims processing guidelines and clients group and company policy and procedure
• Analyze and adjudicate senior member base on HCFA's timeliness and accuracy regulations.
• Analyze and adjudicate Commercial member claims base on federally and non-federally qualified HMO turn around time guidelines.
• Review services for appropriateness of charges and medical necessity and ensure the prior authorization and pre-certification guidelines are applied during claims processing.

Medical Claims Examiner

February 2002 to July 2002

• Review and adjudicate provider claims base on provider and health plan contractual agreement.
• Respond to resolve provider and health plan claims inquiries and apply resolution in a timely fashion.
• Maintain departmental standards on productivity and quality of work.
• Sort and prepare claims for scanning
• Data enter HCFA 1500 Claims billed charges less than $5,000.00 and UB92 less than $30,000.00 into the system for appropriate tracking and processing.

Medical Claims Examiner

April 2001 to December 2001

• Efficient and accurate auditing of claims to verify completeness and conformity
• Effectively conducted medical claims review and processing
• Analyze claims base on plan and issued payment on qualified claims.
• Recorded pertinent date on claims needing further investigation and referred to appropriate department.