Kim Lawrence Gonzales

EXPERIENCE

Senior Medical Claims Processor
National Health Insurance Company - Daman, March 2009 up to present
Abu Dhabi, United Arab Emirates

• Report, audit, evaluate, and process complex outpatient direct, recovery and resubmission claims using ICD9-CM, CPT4, HCPCS, and E&M codes
• Evaluate medical necessity and correlate consistencies in the diagnosis, procedures and drug codes/descriptions stated in the claims, according to accepted medical coding rules & medical guidelines
• Process and audit claims payment ensuring accurate application of agreed discounts & benefit schedules with providers, correct allocation of benefits, collection of deductibles, co-pays, co-insurance, observance of policy limits, and adherence to claims submission protocols
• Give regular provider observations to improve the quality of provider claims
• Report fraud & abuse of providers to superiors
• Organize the receiving & distribution of paper claims to team members
• Communicate clearly & effectively with team members & superiors
• Deliver high quality customer service while respecting medical & work ethics at all times
• Gain the required technical skills to process claims through Documentum & MedNext
• Consistently work efficiently & effectively towards the achievement of challenging daily targets
• Continuously work on improving relevant functional & personal competencies

TRAININGS
• Principles of Insurance
• Excellent Customer Service
(Nov 23-25, 2010)
• Interdepartmental Communication Workshop (June 22, 2011)
• Creative Problem Solving & Decision Making (May 24-26, 2015)
• Medical Terminology (March 6-8, 2016)