JOHANNA DELGADO RODRíGUEZ
Summary
Master's Degree in Criminal Justice and Criminology. With experience, skills, and abilities to carry out investigations on accusations of fraud, waste, and/or abuses committed. I am oriented to develop all my innate abilities and acquire skills to continue growing professionally, thus obtaining optimal results in the assigned area.
Over nine years of experience as a Medical Billing, Audit, and Coding Specialist in medical records and claims. Demonstrated leadership skills with strong analytical and problem-solving skills. Meticulous and enthusiastic with effective communication skills. Expertise in coding and management of CPT, HCPCS, ICD-9, ICD-10 CM/PCS, and CDT. Knowledge of healthcare laws and Federal Regulations.
Overview
24
24
years of professional experience
3
3
Certification
1
1
LIcense
9
9
years of post-secondary education
Work History
Medical Claim Reviewer Coder I
Humana
04.2022 - Current
- • Managed more than 150 cases per day for assignment to coders.
• Processed minimum of 40 claims per day (inpatient and outpatient)
• Managed CWAS data to create the Oops audit dashboard.
• Coding to all specialties (Cardiology, Physical Therapy, Oncology, ER, Radiology, Ambulance, DME, Ophthalmology, Audiology, Assessment and Management, Surgery, etc.) for approval or denial.
• Evaluation and Management Audits. Oversight of regulatory and strategic initiatives to ensure medical claims accuracy.
College Professor
Diferrents
08.2015 - 03.2023
- 2015 – 2018 Professor Dewey University – Juana Diaz, PR
2015 – 2018 University College – Ponce, PR
2019- 2021 Liberty Junior College – Cayey, PR
During my years of experience, I have performed the following functions:
• Teaching courses in Medical Terminology, Medical Coding, Medical Billing, Medical Records Auditing and Claims, Hospital Administration, Coding and Billing for Dental Services, Medical Billing, and Medical.
• Auditing Records and Claims.
• Hospital Administration, Dental Coding and Billing,
• Responsible for teaching Criminal Justice courses (Interview and Interrogation, Fraud, White Collar Crime, and Fraud Detection, Criminal Investigation, Special Criminal Law, Criminology, etc.)
• Student retention rates are 95%.
• Work performance evaluation 98%
Customer Service Representative
NeoDeck Holdings
03.2021 - 01.2022
- • Trained Physicians, Medical coders, and billers in the use of software and programs in the electronic medical record and billing program, including troubleshooting technical problems.
• Identified customer needs, addressed customer complaints, and provided appropriate solutions and alternatives within deadlines.
• Processed customer accounts and document all activities performed.
• Managed over 55 inbound calls and emails, providing front-line customer service or assistance with product and service transactions.
• Work performance evaluation 95%.
Medical Billing Specialist
Dr. Juan Carlos
12.2014 - 12.2017
- Coding procedures, diagnostics, and services
- (Outpatient & Inpatient)
- Billing the claims manual and electronic
- Internal Audits (Medical Records and Claims)
- Reconciliation and resubmit rejected claims.
- Applied payments, adjustments and denials into medical manager system.
- Posted and adjusted payments from insurance companies.
- Precisely completed appropriate paperwork and system entry regarding claims.
- Oversaw regulatory and strategic initiatives to ensure accuracy of medical claims.
- Demonstrated analytical and problem-solving skill by addressing barriers to receiving and validating accurate HCC information.
- Posted charges, payments and adjustments.
Licensed Private Investigator
Private Practice
Santa Isabel, PR
12.2011 - 12.2013
- Responsible for conducting investigations when fraudulent insurance, criminal investigations, robbery, and others
- Implementation of strategies and tools to prevent, detect, investigate, and report Fraud and Abuse as it relates to members, providers, vendors, and employees
- Evaluate business operations to identify risk areas for theft, security, etc
- Conduct interviews, compile documentation and evidence, and maintain investigative reports
- Perform case analysis and support documentation for further legal actions or administrative actions
- Produced professional reports outlining findings of cases, expenses incurred, and any important incidents.
Supervisor
Puerto Rico Housing Department
08.1999 - 11.2009
- Personnel and Office Administration
- Directed the Collections Area (I carried out collection efforts, verified account statements and referred delinquent cases to the Legal Division)
- Completed a study of Property Titles and managed client 20 files per day
- Field investigation to information collected to certify or deny property titles
- Detected, Evaluate, and investigate fraud cases
- Conduct interviews, compile documentation and evidence, and maintain investigative reports
- Manage over 200 cases per month
- Achievements: Standardized, updated, and digitized the accounts receivable of the Collection Area.
Education
No Degree - Certification Medical Coding And Billing
EDUTEC
Coamo, Puerto Rico 07.2013 - 10.2013
Bachelor of Arts - Criminal Justice and Criminology
Interamerican University
Ponce 08.1991 - 07.1998
Master of Science - Criminal Justice And Criminology
Ana G. Méndez University
Santa Isabel, Puerto Rico 01.2011 - 07.2012
Skills
- Medical Coding and Billing
- Coding CPT, ICD-9/10 CM/PCS, HCPCS and CDT
- CMS 1500, UB-04 Forms
- Medical Records Manage and documentation
- Insurance Knowledge
- Supervision and training
- Audit Medical Records and Claims
- Knowledge of Medical Terminology
- Coding Guidelines Knowledge
- Risk Adjustment Knowledge
- Gathered information
- Conduct Fraud investigations
- Experience on Audit Reports
- Strong Team player
- Typing (60 words per minute)
- Quick learner
Affiliations
Associate Member AAPC (American Academy of Professional Coders)
Associate Member ACFE (Association of Certified Fraud Examiner)
Accomplishments
- Microsoft-office
- Practice Fusion
- NeoMed 3.0 & 4.0
- NeoBiller
- Secure Claim
- Secure EMR
- Salesforces
- CSC
- CWAS
- Encoder (Optum)
- LANGUAGES Spanish/English- Full Professional
Certification
- Certified Professional Coder (AAPC)
- Professional Medical Biller Trainer Certified (PMB-T)
- Certified Professional Medical Auditor (AAPC)
- Certified Fraud Examiner (ACFE)
- License Private Investigator
Timeline
Medical Claim Reviewer Coder I
Humana
04.2022 - Current
Customer Service Representative
NeoDeck Holdings
03.2021 - 01.2022
College Professor
Diferrents
08.2015 - 03.2023
Medical Billing Specialist
Dr. Juan Carlos
12.2014 - 12.2017
No Degree - Certification Medical Coding And Billing
EDUTEC
07.2013 - 10.2013
Licensed Private Investigator
Private Practice
12.2011 - 12.2013
Master of Science - Criminal Justice And Criminology
Ana G. Méndez University
01.2011 - 07.2012
Supervisor
Puerto Rico Housing Department
08.1999 - 11.2009
Bachelor of Arts - Criminal Justice and Criminology
Interamerican University
08.1991 - 07.1998
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