Marta P

Healthcare Claims Operations Leader with more than 30 years of progressive experience in medical claims processing, claims adjudication, provider services, claims analysis, and health plan operations. Proven history of advancing from claims data entry and processing roles into Claims Supervisor and Claims Supervisor II leadership positions. Experienced in managing high-performing teams of up to 35 employees, overseeing complex claims operations, ensuring productivity and accuracy standards, conducting audits, training staff, and supporting organizational compliance and operational goals.

Strong knowledge of HMO, PPO, Medicare, Eldercare, Government Programs, CPT/ICD-10 coding, claims systems, contract loading, and reimbursement methodologies.

Claims Supervisor - SunMed International - Doral, FL

(2024-04 - 2026-07)

• Manage the end-to-end processing of medical claims, invoices, and payment activity while maintaining accurate and organized records.
• Submit claims to appropriate insurance payors and conduct consistent follow-up to obtain payment status updates and resolve outstanding claims.
• Collaborate closely with physicians and international personnel to obtain required documentation, provide timely claim updates, and ensure seamless communication throughout the claims process.
• Deliver exceptional customer service to members, external vendors, and internal staff, fostering effective communication and supporting timely issue resolution.
• Partner with the Finance Department to coordinate and facilitate the timely processing and payment of claims to external and internal accounts.
• Monitor pending claims and payment activity, proactively addressing delays and supporting efficient claims resolution.
• Maintain strong cross-functional relationships and contribute to streamlined workflows through attention to detail, organization, and effective communication.

CLAIMS SUPERVISOR II - PARTNERSHIP HEALTH PLAN OF CALIFORNIA - Fairfield, CA

(2016-02 - 2023-11)

• Managed a team of 10 Claims Examiners responsible for manual pricing and adjudication of professional, inpatient, hospice, and rehabilitation claims.
• Oversaw claims suspended in batch due to processing errors prior to entering the adjudication process.
• Directed daily operations, staffing, productivity, accuracy, quality audits, and inventory management for the claims unit.
• Conducted employee performance evaluations, one-on-one meetings, monthly staff meetings, and disciplinary actions.
• Supported payroll administration, recruiting, and new-hire onboarding.
• Trained and coached staff to promote consistent claims processing practices and maintain performance standards.
• Revised and distributed daily claims inventory while assigning work and special projects based on operational priorities.
• Prepared and communicated daily, weekly, and monthly productivity and accuracy reports to Claims Management and Directors.
• Monitored inventory levels and followed up with other departments on claims routed for assistance to ensure timely processing guidelines were met.
• Provided backup supervisory support for three Claims Examiner II units in the absence of their supervisors.

CLAIMS PROCESSING SUPERVISOR - VISTA HEALTH PLAN, INC. - Sunrise, FL

(2004-04 - 2008-08)

• Managed a team of 35 employees responsible for provider calls, claims research, and claims processing issues across multiple health plan products.
• Oversaw claims adjustments and follow-up activities involving provider inquiries and claims-related issues.
• Managed personnel functions including performance evaluations, disciplinary actions, payroll, recruiting, and new-hire training.
• Prepared and distributed daily, weekly, and monthly productivity reports for Claims leadership.
• Assigned special projects and monitored completion to support departmental priorities.
• Maintained communication with providers and ensured appropriate follow-up and resolution of claims issues.
• Trained employees across multiple units and supported consistent processing procedures.
• Consistently met challenging productivity and accuracy goals.

CLAIMS PROCESSING SUPERVISOR - VISTA HEALTH PLAN, INC. - Sunrise, FL

(2002-04 - 2004-04)

• Supervised the night-shift Claims Processing Unit and monitored the daily processing of various claim types.
• Prepared and distributed daily, weekly, and monthly productivity reports for department leadership.
• Managed personnel responsibilities including performance evaluations, disciplinary actions, payroll, recruiting, and employee training.
• Oversaw the distribution and completion of the Claims Electronic Error Report and Processing Unit Reject Report.
• Supported the day-shift supervisor and assumed supervisory responsibilities in their absence.
• Consistently met productivity and accuracy standards.
• Promoted to Claims Supervisor for the Claims Resolution and Provider Call Center Unit.

CLAIMS ANALYST - UNITEDHEALTHCARE OF FLORIDA - Sunrise, FL

(2000-05 - 2001-01)

• Researched complex claims-related issues across HMO, PPO, Eldercare, UNET, and Government products.
• Investigated claims issues submitted by Compliance, Risk Management, Provider Appeals, and Senior Management.
• Applied claims policies, procedures, and member benefits to ensure accurate claims processing.
• Reviewed provider hard-copy contracts against system-loaded contract information to identify contract loading errors.
• Maintained communication with providers to obtain additional information required to resolve claims issues.
• Prepared Excel spreadsheets detailing research findings and claims analysis.
• Applied knowledge of Medicare reimbursement methodologies, including Resource-Based Relative Value System (RBRVS), DRG, and Ambulatory Surgery Center groupers.
• Coordinated special projects and managed project schedules.

PROVIDER SERVICE REPRESENTATIVE - UNITEDHEALTHCARE OF FLORIDA - Sunrise, FL

(2000-01 - 2000-05)

• Supported a special project within the Provider Service Unit focused on unpaid and denied claims.
• Researched claims and contract-related issues and reviewed provider contracts against system-loaded information.
• Resolved enrollee cases and claims status inquiries assigned to the unit.
• Routed adjustments and data-entry requests to the appropriate claims departments.
• Assisted the Maitland team with Pyramid claims processing questions.
• Provided phone support to providers regarding unpaid, underpaid, and contract-related claims issues.

CLAIMS ANALYST - UNITEDHEALTHCARE OF FLORIDA - Coral Gables, FL

(1999-01 - 2000-01)

• Supported a claims cleanup team responsible for Pyramid adjustments and claims processing.
• Processed adjustments and data-entry requests from legacy systems for the Claims Resolution Unit.
• Assisted the supervisor with daily production reports, work assignments, employee training, and staff questions.
• Provided internal and external customer service and claims issue resolution.
• Processed Cosmos Zero adjustments received from Customer Service and Claims Resolution.
• Supported Eldercare audits requested by the Finance Department.

CLAIMS SUPERVISOR - UNITEDHEALTHCARE OF FLORIDA - Coral Gables, FL

(1993-01 - 1999-01)

• Supervised the Hospital and Eldercare Claims Processing Unit.
• Managed daily operations and prepared daily, weekly, and monthly productivity reports for management and leadership.
• Supported employee training for the Adjustments and COB Unit.
• Managed personnel responsibilities including performance evaluations, disciplinary actions, and payroll.
• Assisted the Eldercare Liaison with claims, adjustments, and contract-related issues.
• Processed and approved high-dollar claims.
• Supported the Provider Contracting Department by testing newly loaded contracts and evaluating their impact on claims processing and payments.
• Consistently met challenging productivity and accuracy standards.
• Promoted through progressive claims leadership responsibilities during tenure.

CLAIMS EXAMINER - CAC RAMSAY, INC. - Coral Gables, FL

(1988-11 - 1993-01)

• Adjudicated suspended claims from weekly reports across multiple lines of business.
• Managed manual contractual claims adjudication.
• Worked with the Contract Installation Department to resolve contract loading issues.
• Performed data entry and claims adjudication for Eldercare products.
• Assisted the Provider Eldercare Liaison with claims and adjustment requests.
• Supported training for the Workers’ Compensation Unit.
• Promoted to Claims Supervisor.

CLAIMS DATA ENTRY - CAC RAMSAY, INC. - Coral Gables, FL

(1987-08 - 1988-11)

• Performed physician and facility data entry.
• Assisted with claims adjudication and applied company policies and procedures.
• Promoted to Claims Examiner.

ACCOUNTS PAYABLE CLERK - CAC RAMSAY, INC. - Coral Gables, FL

(1987-05 - 1987-08)

• Prepared and processed vendor payments and invoices.
• Organized and maintained vendor invoice files.
• Prepared documents for scanning and transfer to the Claims Department.

Microcomputer Operations - Florida International Institute (1988)

High School Diploma