Cynthia Lopez
San Antonio,United States
Summary
Senior Claims Benefits Analyst with deep knowledge of benefits and medical claims industry. Solid abilities in developing objectives and strategies for various cafeteria and voluntary benefits. Excellent skills compiling, coding, categorizing and auditing information to process claims and administer benefits.
Overview
23
23
years of professional experience
Work History
Senior Claims Escalations Analyst
Aetna, A CVS Health
02.2009 - Current
- Maintain knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
- Explain benefits to plan participants in easy to understand terms in order to educate each on available options.
- Verify member benefits enrollment for accuracy of all inputted data.
- Pay or deny medical claims based upon established claims processing criteria.
- Review provider coding information to report services and verify correctness.
- Collaborate with claims department and industry anti-fraud organizations to resolve claims.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Resolve issues and inquiries from plan participants regarding health and welfare benefits and deductions through correspondence.
- Monitor day to day activities of claim volumes to ensure all matters adhere to established Service Level Agreements.
- Continently maintain financial accuracy meeting or exceeding 99% quality metrics.
Business Processing Outsourcing Representative
ACS INC
04.2007 - 02.2009
- Reported policy changes and company conditions affecting customer satisfaction.
- Evaluated accuracy and quality of data entered into agency management system.
- Researched claims and incident information to deliver solutions and resolve problems.
Medical Claims Analyst
Zenith Administrators
02.2000 - 04.2007
- Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations.
- Managed workflow and escalations of high dollar claims.
- Responded to correspondence from insurance companies.
- Trained new employees on policy and procedures regarding special claims processing.
- Developed training documents and presentation.
Education
Associate of Applied Science -
Alamo Colleges District
San Antonio, TX05.2023
Skills
- Benefits administering
- Claims Investigations
- Claims Evaluations
- Claims and Case Audit
- Claims Understanding
- Training Program Development
- Client Correspondence
- Appeals and Resolutions
Timeline
Senior Claims Escalations Analyst
Aetna, A CVS Health
02.2009 - Current
Business Processing Outsourcing Representative
ACS INC
04.2007 - 02.2009
Medical Claims Analyst
Zenith Administrators
02.2000 - 04.2007
Associate of Applied Science -
Alamo Colleges District
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