Elizabeth Pedroza Email & Phone Number | Responsible for accurate and timely adjudication of claims according to guidelines. Claims processing based upon contractual and/or CalOptima agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures. Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, ie co-payments, deductibles, etc. Process Claim Exception Reports as assigned Maintain quality and productivity standards as set by management. Provide backup phone coverage for the Provider Inbound Queues. Respond to incoming calls from providers of service in a timely and courteous manner. Resolves less complex issues as presented. Refers complex issues appropriately. Alerts manager or supervisor of issues that impact production and quality, ie incorrect database configurations, non-compliant claims, etc. Process claims based on compliance regulation and timeframes. Review services for appropriateness of charges and apply authorization guidelines during claims processing. Prepare written requests to providers; follow up and handle completion of claim for returned correspondence. Customer service and organizational skills required. Other duties as assigned by management. Required Skills. Pre-Certificate/Authorize requests Request information from providers and insurance companies Support nursing staff Provide customer service for callers request status Review nurse DALS for completion & close service lines when finished Handle status inquiries via email or phone Cover reception desk Perform Other Designated Duties.

Elizabeth Pedroza

Responsible for accurate and timely adjudication of claims according to guidelines. Claims processin...
Orange County, Orange County, United States

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Elizabeth Pedroza’s Email epedroza@caloptima.org

Elizabeth Pedroza’s Phone Numbers

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Elizabeth Pedroza’s Location Orange County, Orange County, United States

Elizabeth Pedroza’s Current Industry CalOptima

Elizabeth Pedroza’s Prior Industry CorVel Corporation | Doctors Hospital of West Covina

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Work Experience

CalOptima

Claims Examiner

2016-03-01 00:00:00 - Present

CorVel Corporation

Administrative Assistant

2013-08-01 00:00:00 - 2016-03-01 00:00:00

Doctors Hospital of West Covina

Admitting Specialist

2011-04-01 00:00:00 - 2012-08-01 00:00:00

Skills

No Skills Available

Languages

No Languages Available

FAQ About Elizabeth Pedroza

Elizabeth Pedroza is located at
Orange County, Orange County, United States

Elizabeth Pedroza is a Responsible for accurate and timely adjudication of claims according to guidelines. Claims processing based upon contractual and/or CalOptima agreements, involving the use of established payment methodologies, Division of Financial Responsibility, applicable regulatory legislation, claims processing guidelines and company policies and procedures. Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, ie co-payments, deductibles, etc. Process Claim Exception Reports as assigned Maintain quality and productivity standards as set by management. Provide backup phone coverage for the Provider Inbound Queues. Respond to incoming calls from providers of service in a timely and courteous manner. Resolves less complex issues as presented. Refers complex issues appropriately. Alerts manager or supervisor of issues that impact production and quality, ie incorrect database configurations, non-compliant claims, etc. Process claims based on compliance regulation and timeframes. Review services for appropriateness of charges and apply authorization guidelines during claims processing. Prepare written requests to providers; follow up and handle completion of claim for returned correspondence. Customer service and organizational skills required. Other duties as assigned by management. Required Skills. Pre-Certificate/Authorize requests Request information from providers and insurance companies Support nursing staff Provide customer service for callers request status Review nurse DALS for completion & close service lines when finished Handle status inquiries via email or phone Cover reception desk Perform Other Designated Duties.