Sylvia Sanchez

2020 to Current

• Manager of the Claims Department for multiple IPAs managed by MHM Healthcare, Inc.
• Create and update Claims Department policies and procedures as required by Health Plans, DMHC, and CMS.
• Participate in audits with governing agencies and health plans.
• Prepare monthly timeliness and quarterly reports for Medi-Cal Line of Business.
• Oversee the weekly check run audits for multiple IPAs.
• Monitor claims inventory for compliance purposes.
• Proficient in QuickCap Database.

2017-2020 Claims Supervisor

• Managed claims processing for healthcare services and provider reimbursements.
• Assisted Claims Manager with preparing health plan audits.
• Assisted with monthly and quarterly reporting for claims.

2014-2017

• Claims Examiner for professional claims (DME, Radiology, Anesthesia, Specialty claims).
• Attached authorizations to claims.
• Verified eligibility for members.
• Verified member benefits and MOOP.
• Processed COB claims.

Claims Examiner for Horizon Valley Medical Group

• Processed and adjudicated professional claims (DME, Specialty, Anesthesia, COB, Radiology).
• Processed and adjudicated outpatient hospital service.
• Worked with the Claims Manager to prepare Health Plan Audits.
• I answered customer service calls for claim status.
• Familiar with EzCap database.

Claims Examiner for IMG Medical Group

• Processed and adjudicated professional claims (DME, Specialty, Anesthesia, Radiology, and COB).
• Processed and adjudicated hospital services.
• Worked with the Claims Manager to prepare health plan audits.
• Verified member eligibility.
• Verified member benefits, MOOP, if applicable.
• I answered customer service calls for claim status.
• Familiar with the EzCap database.