Barbara Cruz
Medical Mutual
Lorain,OH
22
years of professional experience
Experienced Lead Claims & Customer Service Representative with 20+ years resolving benefits, eligibility, and claims issues. Strong in claims research, claim adjustments, problem resolution, and active listening, with a record of supporting complex Medicare Advantage, Medicaid, and dental claims.
Work History
Lead Claims & Customer Service Representative
3 Years- Resolved member inquiries regarding benefits, eligibility, and claims using accurate plan information.
- Investigated claim issues by reviewing account records and coordinating with internal departments.
- Documented customer interactions in CRM systems, maintaining detailed case notes and follow-up actions.
- Processed routine service requests while maintaining compliance with HIPAA and confidentiality standards.
- Adapted quickly to changing procedures, policies, and system updates in fast-paced a fast-paced support environment.
- De-escalated frustrated customers by applying active listening and solution-focused communication.
- Assisted and mentored staff with claims questions, procedures and customer service concerns.
- Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
- Processed dental insurance claims and reviewed adjustments to support accurate claim outcomes.
- Researched complex claims and coordinated refund activity with the finance department.
- Supported Medicare Advantage and Medicaid claims processing, adjustments, and issue resolution.
- Applied strong research and communication skills to clarify claim issues and support timely follow up.
Sr. Claims & Customer Service Representative
10 Years 5 Months- Resolved member inquiries regarding benefits, eligibility, and claims using plan guidelines and call documentation systems.
- Interpreted dental insurance policies to explain coverage details, copays, deductibles, and authorization requirements.
- Resolved escalated customer issues, restoring confidence in the company's commitment to service excellence.
- Documented service interactions accurately in CRM systems to maintain complete and compliant member records.
- Reviewed and adjudicated complex dental claims in accordance with plan provisions and the company guidelines
- Assisted with quality audits and provided guidance to newer team members.
- Collaborated with team members to ensure timely resolution of complex member concerns.
- Performed adjustments for overpayments, underpayments, coordination of benefits, duplicate claims and system processing errors.
Claims & Customer Service Rep. II
8 Years 3 Months- Resolved member inquiries regarding benefits, claims, and coverage with accurate, compliant guidance.
- Interpreted policy provisions to explain plan details, eligibility, and billing questions clearly.
- Documented call activity, case notes, and service actions in customer information systems.
- Escalated complex issues to appropriate departments while maintaining timely member follow-up.
Education
High School Diploma
Skills
Claims Research
Claims Review
Medicare Advantage Claims
Medicaid Claims
Claims investigation
Claims adjudication
Claim reconciliation
Refund processing
Critical thinking
Problem resolution
Active listening
Customer service
Problem resolution
Timeline
Lead Claims & Customer Service Representative
Medical Mutual
07.2022 - 07.2025Read More
Sr. Claims & Customer Service Representative
Medical Mutual
02.2012 - 07.2022Read More
Claims & Customer Service Rep. II
Medical Mutual
11.2003 - 02.2012Read More
Valley Forge
High School Diploma
Read More