Cecilia Cervantes
Lakewood,CA
Summary
Dynamic Senior Claims Manager with a proven track record at Quality Health Partners, specializing in claims management and strategic planning. Expert in reducing claims processing time and enhancing team performance through effective communication and staff training. Recognized for implementing innovative solutions that significantly decreased fraud incidents and improved operational efficiency.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Senior Claims Manager
Quality Health Partners
02.2024 - Current
- Managed a team of claims adjusters, ensuring thorough investigations and accurate assessments of liability.
- Led cross-functional teams in the development of innovative solutions to reduce fraud incidents within the department.
- Managed high caseloads while maintaining excellent attention to detail throughout each claim''s lifecycle from initial reporting to final settlement or litigation process.
- Analyzed complex loss scenarios to determine appropriate coverage limits, fostering informed decision-making across the organization.
- Mentored junior staff members on effective negotiation techniques, fostering professional growth within the team.
- Collaborated with legal counsel on high-profile cases, protecting company interests and minimizing financial losses.
- Achieved significant reduction in outstanding reserves through proactive case management strategies and timely settlement negotiations.
- Reduced claims processing time by implementing efficient workflow systems and streamlining procedures.
- Spearheaded the integration of new technology platforms for tracking claims data, resulting in improved reporting capabilities.
Billing Consultant
Self Employed
01.2019 - Current
- Generated invoices upon receipt of billing information and tracked collection progress.
- Streamlined invoicing procedures, resulting in faster turnaround times for bill generation.
- Ensured compliance with industry regulations, maintaining up-to-date knowledge of changes and best practices in the field of billing.
- Established a strong rapport with clients, fostering long-term relationships built on trust and effective communication around billing matters.
- Implemented electronic invoicing system, reducing paper usage and increasing overall efficiency within the department.
- Reviewed existing contracts to identify missed revenue opportunities or inaccuracies that could impact future billing cycles.
- Worked closely with finance department to reconcile accounts receivable balances, providing accurate financial reporting for decision-making purposes.
- Maintained detailed records of all client interactions regarding billing matters, contributing to a comprehensive customer relationship management database.
- Negotiated favorable payment terms with clients, resulting in improved cash flow for the organization.
- Participated in monthly financial review meetings, providing insights and recommendations on how to improve billing-related performance metrics.
- Communicated with clients to review and verify client billing requirements.
Provider Relations Manager
Optum
10.2012 - 01.2024
- Answered provider inquiries via email, telephone and written correspondence.
- Managed provider relations mailbox by triaging inquiries, facilitating resolution of incoming requests and forwarding requests to appropriate parties.
- Fostered strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying on-site enrollment opportunities.
- Contributed to and enhanced audit processes to maximize quality management standards.
- Assisted with physician recruitment by identifying specific providers within designated territories, negotiating rates for new physicians and distributing provider agreements.
- Initiated physician and hospital orientations to support ongoing education of health care provider community.
- Negotiated favorable contract terms with new partners while maintaining positive relationships with existing ones, leading to sustained growth in the provider network.
- Contributed significantly towards achieving company''s growth targets by effectively managing a large portfolio of healthcare providers across different geographical regions.
- Reviewed financial performance data for contracted providers regularly, identifying areas where improvements could be made in order to optimize revenue generation potential.
- Developed comprehensive reports highlighting trends and performance metrics of providers, enabling informed decision-making at all levels of management.
- Improved provider satisfaction through the development and implementation of targeted training programs for staff on provider policies and procedures.
- Served as a liaison between healthcare providers and internal departments such as claims processing or customer service, facilitating effective resolution of any issues that arose during day-to-day operations.
Medical Assistant
Catalina Medical Center
01.2012 - 09.2012
- Sanitized, restocked, and organized exam rooms and medical equipment.
- Obtained client medical history, medication information, symptoms, and allergies.
- Directed patients to exam rooms, fielded questions, and prepared for physician examinations.
- Performed medical records management, including filing, organizing and scanning documents.
- Built strong relationships with patients through effective communication skills that foster trust in the clinic''s commitment to quality care.
- Assisted physicians with minor surgeries, including preparing operating room and sterilizing instruments.
- Ensured patient safety and comfort during examinations, effectively addressing concerns and answering questions.
Medical Assistant
Karing Pediatrics
01.2010 - 12.2011
- Boosted patient satisfaction by providing compassionate care and promptly addressing needs during visits.
- Enhanced clinic efficiency by assisting physicians with routine procedures and diagnostic tests.
- Coordinated patient referrals to specialists or other healthcare providers as needed for comprehensive care management plans.
- Improved patient experiences by efficiently managing appointments and maintaining organized medical records.
- Optimized appointment scheduling processes to minimize conflicts and maximize physician availability for patients.
- Contributed to positive health outcomes by educating patients on preventative measures, treatment plans, and follow-up care instructions.
- Reduced wait times by swiftly processing insurance claims, verifying coverage, and obtaining pre-authorizations when necessary.
- Collaborated with interdisciplinary healthcare teams to provide coordinated care.
Education
Bachelor Of Science In Business - Business
University of Phoenix
Tempe, AZ04.2023
Skills
- Claims management expertise
- Time management
- Claims processing efficiency
- Effective communication
- Staff training and development
- Data analysis capabilities
- Strategic planning
- Project management expertise
- Decision-making proficiency
Certification
Project Management Certificate
Timeline
Senior Claims Manager
Quality Health Partners
02.2024 - Current
Billing Consultant
Self Employed
01.2019 - Current
Provider Relations Manager
Optum
10.2012 - 01.2024
Medical Assistant
Catalina Medical Center
01.2012 - 09.2012
Medical Assistant
Karing Pediatrics
01.2010 - 12.2011
Bachelor Of Science In Business - Business
University of Phoenix
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