ASHLEY CRUZ
Boise,ID
Summary
Dynamic configuration analyst committed to optimizing systems performance,streamline workflows and providing data driven results to create improved processes. Performs timely work proposals and testing alongside routine troubleshooting to facilitate system transitions and minimize delay. Simplifies complex topics and processes to make technical interactions to provide seamless interactions internally. Organized and dependable at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
14
14
years of professional experience
Work History
Configuration Analyst
Blue Cross Of Idaho
04.2022 - Current
- Intake and triage Service Now requests to review for configuration and analysis
- Review and propose possible claims configuration changes for LOBs and products
- Troubleshoot issues to include performing business UAT
- Create and provide analytics on Retro Adjustment tickets for provider contracts, pricing, product changes or updates
- ITS Reporting and Analytics through DataNet 3 and Plan Connection
- ITS Releases and Implementation
- Inter Plan Projects: Bluecard Modernization, with direct project work in Real Time Messaging
- Facilitates New Code Edit Workgroup by collaboration and review for new/termed codes, ICD-10, HCPCS etc for configuration and benefit application
- Claims Automation Project to include vendor (HPA/Sagility) work, testing & implementation
- Analyzed existing systems and databases and recommended enhancements to solve business needs
- Offered input for complex documents to support claims processes for final versions.
- Collaborated with upper management to drive strategy and implement new processes.
- Communicated and explained business requirements to team members to understand and implement functional demands.
- Developed diagrams to describe and lay out logical operational steps.
- Developed and maintained courteous and effective working relationships.
Operation Specialist
BlueCross Of Idaho
08.2021 - 04.2022
- Processed general Bluecard medical claims | Verified benefits and payments | Review processing errors |Maintained and met processing efficiency scores and quality, for about 7 months with overall 3 years in Home
- Bluecard providing administrative support to over 20 staff members
- I continued to support staff in the capacity of overseeing examiner duties, training and other department functionalities
- I also conduct reports and analysis of data to provide process improvement to my team.
- Helped meet changing demands by recommending improvements to business systems or procedures.
- Frequently inspected production area to verify proper equipment operation.
- Developed effective improvement plans in alignment with goals and specifications.
- Evaluated customer needs and feedback to drive product and service improvements.
- Devised and implemented processes and procedures to streamline operations.
- Generated reports detailing findings and recommendations.
- Evaluated staff performance and provided coaching to address inefficiencies.
CLAIMS EXAMINER II
BlueCross of Idaho
05.2019 - 08.2021
- Processed general/complex Bluecard medical claims
- Resolution processing of claim adjustments, inquiries, and other Plan to Plan inquiries
- Provided training and support with other examiner staff
- Responsible for inventory reports and other area reports for department
Claims Examiner I
Blue Cross Of Idaho
11.2018 - 05.2019
- Processing ITS Home claims
- Identify any claims issues, e.g. benefits, pricing etc.
- Assisted in claims documentation and training
- Generated inquiries to Host plans
MEDICAL BILLING ASSOCIATE
FHP Health Center
08.2013 - 09.2018
- Review, prepare and submit medical claims for multi-specialty services to include verifying benefits, coverage and obtaining pre-certifications
- Experience working with insurance carriers such as Aetna, Cigna, Bluecross Blueshield
- Geoblue, AARP, Medicare/Medicaid, and Tricare, Veterans Administration, Triwest
- VAPCC3 and other small payers |Responsible for providing accounst receivable reports to billing supervisor/manager & follow up on account receivable and provide prompt payment letters, if needed |Resolve and appeal claim denials for assigned payers |
- Report and update coordination of benefits for assigned payers | Prepared patient statements/invoices for services to include forwarding outstanding accounts to collection agency | Posting of insurance payments and verifying proper provider reimbursement | Audit medical records and claims ensure proper billing practices, validate accuracy of charges, patient diagnosis and coding edits | Reconcile and research recoupment/recovery audits from payers | Update and maintain CPT and
- HCPCS codes within system to include assigned fee schedule | Reconciling oncology drug reimbursement with pharmacy department requisition to ensure profitability
PATIENT SERVICE REPRESENTATIVE
FHP Health Center
03.2010 - 08.2013
- Appointment scheduling and entering patient demographics | Obtaining insurance eligibility and benefit coverage | Collecting patient payments |Answer telephone inquiries and sending messages to provider/nurse| Closing out daily collections and creating day sheets | Printing patient lab requests, medical records, and other requested information
Education
High School Diploma -
John F Kennedy High School
Tamuning, Guam06.2008
Skills
- MS Office: Word/Excel/Note
- Problem Solving & Analytical Thinking
- Keen attention to detail
- Excellent Organizational skills
- Information Extraction
- Team Support
- Training Junior Team Members
- Change Management Process
- Design Development
- Product Release
- User Acceptance Testing (UAT)
- Project Proposals
- Root Cause Analysis Expertise
- Client Requirements
- SQL Data Querying and Reporting
References
Jamie Smith
jamie.smith@bcidaho.com
(986) 224-6960
Amy Guerra
amy.guerra@bcidaho.com
(986) 224-5168
Andru Maldonado
andru.maldonado@bcidaho.com
(986) 224-6850
Timeline
Configuration Analyst
Blue Cross Of Idaho
04.2022 - Current
Operation Specialist
BlueCross Of Idaho
08.2021 - 04.2022
CLAIMS EXAMINER II
BlueCross of Idaho
05.2019 - 08.2021
Claims Examiner I
Blue Cross Of Idaho
11.2018 - 05.2019
MEDICAL BILLING ASSOCIATE
FHP Health Center
08.2013 - 09.2018
PATIENT SERVICE REPRESENTATIVE
FHP Health Center
03.2010 - 08.2013
High School Diploma -
John F Kennedy High School