Ma. Kathrina Ann M. Espaldon

About the Candidate

I am a registered nurse and an experienced (9 years) claims adjudicator for UHG/Optum with an extensive background in adjudicating/processing different types of medical claims from hospitals, doctors, dental clinics, and prescriptions in a timely manner. The main task and responsibility as a claims adjudicator are to make sure I am paying or denying the claim correctly; according to plan benefits, contracts, eligibility, state variations, or riders. When processing a claim, I check and cross-reference the HCFA/UB09 form if they match in our system, if the diagnosis codes billed (ICD 9 or 10) correspond to the procedure or HCPCS/CPT code/s, and if they were billed with the correct modifiers, prescription claims, dental claims, superbills and other forms (receipts/superbills). Apart from that, I check the claims if they are a partial duplicate, entirely duplicate, or fraudulent; calculate amounts for anesthesia, primary, and assistant surgeon’s claim accordingly. I also handle correspondence (and with medical records), appeals, and phone call inquiries regarding EOBs, COBs, denials, appeals, or general inquiries regarding the insured’s plan and benefits, deductible, and copay as well as benefit disputes. I was also fully trained to process ACA claims and processed ACA claims briefly.

I also call billing departments if there is any verification or clarification needed; doctors/nurses or the medical records department to obtain additional information or records for review if needed; send out EOBs every after processing of claims and send letters to explain the coverage of the claim, reason of denial and or if the insured’s address is different in the claim form to our system.

I recently worked as a remote administrative assistant in a fertility clinic based in San Diego, California.

These tasks and responsibilities were in adherence to the company and HIPAA regulations.