Summary
Overview
Work History
Education
Skills
Accomplishments
Timeline
Awards and Achievements
Generic
ELIZABETH A. BOLDING

ELIZABETH A. BOLDING

Fontana

Summary

Collaborative leader partners with coworkers with a history of meeting company goals utilizing consistent and organized practice. Eager to contribute to team success and further develop professional skills. Interested in applying these skills and willing to learn new tasks to gain more experience in Managed Health Care.



Overview

27
27
years of professional experience

Work History

Provider Dispute Resolution Specialist

United Healthcare/NAMM California-Part of Optum
05.2025 - Current
  • Answered PDR questions, Post Real Time Payment and Approve Special Checks, Trained new PDR Specialists, Reviewed and Audited work from the new PDR Specialists. Releasing Header Holds, attached documents to the PDR images for Specialists and pulled DRG and APC Rates for Institutional Claims.
  • Pull Reports for PDR - CMS PDR Received Report, Compliance Warning Report, Letter Warning Report, Multiple Co-Codes Report, Provider on Hold Report. Non-Provider on Hold Report, Specialist Production Reports, TAT Reports for PDR, MOOP and BATCH.
  • Health Net / United Healthcare Monthly Reports.
  • Quarterly Reports – for 16 Health Plans, each one is very specific on the information that is pulled.
  • Pulling Legal Documents that could range between 1 to 250 claims from 4 different people, having to print out the EOB, Gizmo/Claim Images, Xcelys/Claim Notes, Auth Notes, DOFRs, and the PDR Letters.

Provider Dispute Resolution Specialist

United Healthcare/NAMM California
01.2022 - 05.2025
  • Processed Reworks.
  • Answered PDR questions, Post Real Time Payment and Approve Special Checks, Trained new PDR Specialists, Reviewed and Audited work from the new PDR Specialists. Releasing Header Holds, attached documents to the PDR images for Specialists and pulled DRG and APC Rates for Institutional Claims.

Provider Dispute Resolution Specialist

NAMM California
02.2012 - 01.2022
  • Review Appeals from Providers and Health Plan. Processed and adjusted Commercial/Senior Claims for various Health Plans to be paid correctly and sent Refund Requests for Overpayments made in error. Called Providers regarding their disputes.

Denial Coordinator

NAMM California
03.2010 - 02.2012
  • Review processed claims that are denied due to no prior authorizations on file, no current eligibility, and review claims that are denied for not a covered benefits. Making calls to the member’s Primary Care Providers, referring providers and Health Plans to research if member’s responsibility. Send Denial Letters to the member and the Primary Providers. Process Commercial and Senior Claims for various Health Plans. Processed Stop Loss claims for the Institutional Claims Department. Processed PDR’s for the PDR Department.

Claims Examiner

Kimco Staffing/NAMM California
10.2009 - 03.2010
  • Process Commercial and Senior Claims for various IPA’s and Health Plans for Mercy, PCA and PrimeCare.

Claims Specialist, Senior

Physician Associates in Division of HCP
05.2005 - 03.2009
  • May of 2005 was promoted from an Examiner II to work for the Research and Resolution Unit. Reviewed disputes from Providers, Emails and Customer Service Inquiries.
  • Answered calls from providers with disputes, overpayments and underpayments, reversed payments, and adjusted claims to be paid correctly, familiar with the MC400.
  • Processed and adjusted Commercial/Senior Claims for various Health Plans, adjusted claims and sent Overpayments Notices due to Audits.
  • Provided all documents for the PDR Health Plan Audits and attended the Exit interviews with the Manager and the Health Plan Auditors.

Medical Claims Processor

Huntington Provider Group
03.1998 - 05.2006
  • Pre-logging/data entry, processed Encounter Data. Promoted to Claims Examiner I, where I Processed Capitated Claims and Senior Claims for various Health Plans.
  • January 2000 was promoted to Claims Examiner II, where I processed Commercial and Senior Claims for various Health Plans.
  • Researched and resolved complex medical claims issues to support timely processing.

Education

Certificate - Business Operations

National Education Center/Bryman Collage
Rosemead, CA
03.1996

Certificate - Data Entry

El Monte/Rosemead Adult School
Rosemead, CA
11.1994

Diploma - undefined

Rosemead High School
Rosemead, CA
06.1992

Skills

  • Bilingual – English/some Spanish
  • Accurate Data Entry, Office Procedures, Typing-50-65 WPM, Ten key by touch-15,000 KPH
  • Knowledgeable with HMO, POS, Medi-cal, Medicare, ICD-10, CPT Coding, Anesthesia calculation, Knowledge of RBRVS
  • Self Starter/Works well Independently
  • Knowledge of Computer Programs, Microsoft Windows, Microsoft Office Word and Excel, Microsoft Outlook, MS400/AS400, Paradigm, Flash Code, Xcelys and Citrix
  • Teamwork and collaboration
  • Reliability
  • Organizational skills
  • Legal document preparation and filing documents
  • Interpersonal skills and communication
  • Professionalism
  • Independent Decision-making
  • Self motivation
  • Professional ethics
  • Maintaining confidentiality
  • Impartiality
  • Alternative dispute resolution
  • Dispute analysis
  • Problem-solving abilities
  • Multitasking Abilities
  • Effective communication
  • Adaptability and flexibility
  • Continuous improvement
  • Willing to do extra work to gain valuable experience

Accomplishments

  • In recognition “HITTING THE MARK” for the performance target Incentive Bonus Program for Quality and Productivity from 2001-2006.
  • 97-100% accuracy rating for the years of 1998-present
  • Dec 2002-Feb 2003, November 2005 helped Quality Control Dept.
  • May 2003-July 2003, April 2004 helped Special Project Dept.
  • Dec 2003- Jan 2004 HEDIS Project – calling members to encourage them to follow-up on their visits and sent requests to UM for Authorization to be approved for their yearly exams.
  • May 2006-Promoted to the Research and Resolution Unit, trained new Claim Examiners II on how to process PCP, Radiology, Surgical Pathology and Lab claims.
  • January 2018 – present – received recognition Bravo Awards for training and performance.

Timeline

Provider Dispute Resolution Specialist

United Healthcare/NAMM California-Part of Optum
05.2025 - Current

Provider Dispute Resolution Specialist

United Healthcare/NAMM California
01.2022 - 05.2025

Provider Dispute Resolution Specialist

NAMM California
02.2012 - 01.2022

Denial Coordinator

NAMM California
03.2010 - 02.2012

Claims Examiner

Kimco Staffing/NAMM California
10.2009 - 03.2010

Claims Specialist, Senior

Physician Associates in Division of HCP
05.2005 - 03.2009

Medical Claims Processor

Huntington Provider Group
03.1998 - 05.2006

Certificate - Data Entry

El Monte/Rosemead Adult School

Diploma - undefined

Rosemead High School

Certificate - Business Operations

National Education Center/Bryman Collage

Awards and Achievements

· In recognition “HITTING THE MARK” for the performance target Incentive Bonus Program for Quality and Productivity from 2001-2006.

· 97 - 100% accuracy rating for the years of 1998 - present.

· Dec 2002 - Feb 2003, November 2005 helped Quality Control Dept.

· May 2003 - July 2003, April 2004 helped Special Project Dept.

· Dec 2003 - Jan 2004 HEDIS Project - calling Members to encourage them to follow-up on their visits and sent requests to UM for Authorization to be approved for their yearly exams.

· May 2005 - Promoted to the Research and Resolution Unit/PDR Dept, trained new Claim Examiners II on how to process PCP, Radiology, Surgical Pathology and Lab claims.

· December 2012 - Promoted to PDR.

· January 2018 - present - received recognition Bravo Awards for Training, Performance, Integrity and Collaboration.

ELIZABETH A. BOLDING