ASHLEY CRUZ

• Proven operations leader with a track record of improving enterprise claims performance, including redesigning NP Scorecard metrics and aligning outcomes with BCBSA compliance standards.
• Drives automation and process modernization, increasing first‑pass adjudication rates and reducing pend volumes by thousands monthly across high‑impact claim workflows.
• Expert in transforming reporting structures—streamlining reviews, elevating data visibility, and enabling leadership decision‑making through robust dashboards and analytics.
• Leads cross‑functional initiatives spanning ITS cutovers, RTM enhancements, ACF automation, and systemic error resolution to strengthen end‑to‑end claims operations.
• Skilled in advanced data analysis, using trend insights, root‑cause evaluation, and claim‑impact assessments to inform organizational priorities and operational strategy.
• Builds high‑performing teams by expanding cross‑training, upskilling examiners in complex claim types, and establishing clear documentation and workflow standards.
• Strengthens vendor performance and utilization through targeted training, expanded SOW, and collaboration that reduces overtime and improves throughput.
• Trusted partner to Legal, G&A, EBS, SIU, PI, and Customer Service, improving cross‑department alignment, timeliness, and issue resolution.
• Leads operational readiness for new releases, partner plan changes, and system transitions, ensuring accuracy, compliance, and seamless execution.
• Known for reducing silos, improving prioritization, and driving measurable quality and efficiency gains at the unit and department levels.

• Configured Facets tables and applications to enhance claims accuracy and efficiency.
• Managed and coordinated the Releases and Implementation of Interplan Teleprocessing (ITS/Bluecard) to ensure seamless transitions.
• Conducted research, analysis, and documentation of business requirements and functional specifications for various projects.
• Delivered clear and detailed documentation, improving project clarity and stakeholder understanding between business stakeholders and the development team.
• Communicated business needs and validated solutions with stakeholders, ensuring alignment with business objectives.
• Effectively established understanding of business requirements with team members for implementation of functional demands.
• Contributed to the validation of complex documents in support of claims processes for final versions.
• Executed and coordinated business user acceptance, regression testing, peer review, and associated test initiatives.
• Designed thorough test plans and scripts aimed at resolving post-deployment defects.
• Played a key role in the Claims Automation Project by coordinating vendor (HPA/Sagility) work, executing thorough testing procedures,and overseeing effective implementation.
• Enhanced compliance by developing scripts, reports, analytics, and efficient processes.
• Developed efficient MSSQL queries to handle Retro Adjustment tickets involving updates and changes in provider contracts, pricing, and product information.
• Inter Plan Projects, including Bluecard Modernization, with direct project work in Real-Time Messaging implementation.
• Analyzed existing systems and databases, and recommended enhancements to solve business needs.

• Managed and resolved complex claim inquiries with prompt resolutions.
• Maintained claims inventory and metrics for Interplan Scorecard measures
• Provided administrative support to over 20 staff members by overseeing examiner duties, training, and other department functionalities.
• Conducted reports and analysis of data to provide process improvement to my team.
• Assisted in meeting changing demands by suggesting enhancements to business systems or procedures.
• Developed effective improvement plans in alignment with performance 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.

• 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 the department.

• Processing ITS Home claims
• Identify any claims issues, e.g. benefits, pricing etc.
• Assisted in claims documentation and training
• Generated inquiries to Host plans

• Oversaw the processing of medical claims for multi-specialty services by reviewing, preparing and submitting them accurately after verifying benefits, coverage and obtaining pre-certifications.
• Delivered accurate accounts receivable reports to billing supervisor/manager, actively following up on outstanding payments.
• Implemented effective use of billing practices and coding guidelines
• Audit medical records and claims to ensure proper billing practices, validate accuracy of charges, patient diagnosis, and coding edits.
• Ensured profitability by reconciling oncology drug reimbursement with pharmacy department requisition.
• Resolved coding errors by working directly with providers and staff members.
• Developed strategies to improve collection efforts of outstanding balances due from payers.
• Submitted appeals using provider portals and phone communication.

• Applied administrative knowledge and courtesy to explain procedures and services to patients.
• Processed payments using cash and credit cards, maintaining accurate records of transactions.
• Recommended service improvements to minimize recurring patient issues and complaints.
• Trained new staff on filing, phone etiquette and other office duties.

• Coordinated patient appointment scheduling and accurately entered demographic information into the system
• Verified insurance eligibility, coverage, and benefits to ensure accurate billing
• Collected and processed patient payments, including co-pays and outstanding balances
• Managed high-volume telephone inquiries and routed messages to providers and nursing staff
• Reconciled and closed daily financial collections; prepared and maintained day sheets
• Generated and distributed patient documents, including lab requisitions, medical records, and other requested information