Karoline L. Diaz
Meridian,USA
Summary
Seasoned professional with proven ability to manage and lead teams effectively. Successfully implemented process improvements that enhanced operational efficiency and team productivity. Demonstrated strong problem-solving and communication skills to drive team success.
Overview
20
20
years of professional experience
Work History
Overpayment Analyst
Cambia Health Solutions
06.2023 - 06.2024
- Identified, investigated, and recovered overpayments to providers and members
- Reviewed claims, data, and documentation to identify discrepancies
- Issued refund requests, adjusted claims, and initiated recoupments
- Effectively communicated with providers, members, and internal stakeholders
- Resolved complex overpayment issues
- Identified support issues and initiated actions for resolution
- Conducted ad-hoc analysis to support business inquiries
Manager, Benefits Administration
Blue Cross of Idaho
06.2014 - 07.2021
- Managed teams responsible for administering home, host Blue Card, commercial, ASO, and dental benefits
- Oversaw claim processing, member inquiries, and provider relations
- Developed and implemented process improvements to enhance efficiency and accuracy
- Ensured compliance with regulatory requirements and company policies
- Provided leadership and coaching to team members
- Maintained InterPlan Programs scorecard and achieved high score of 100% for 6 months consecutively
- Monitored team productivity and performance to support goals
- Assigned, prioritized, and delegated tasks and responsibility to departmental employees
- Coached and motivated team, driving sales and delivering exceptional customer service
- Communicated plans and actions to meet departmental goals
- Collaborated with staff to develop and carry out processes
- Managed and motivated employees to be productive and engaged in work.
- Accomplished multiple tasks within established timeframes.
- Maintained professional, organized, and safe environment for employees and patrons.
- Enhanced customer satisfaction by resolving disputes promptly, maintaining open lines of communication, and ensuring high-quality service delivery.
Senior Business Analyst
Blue Cross of Idaho
01.2013 - 06.2014
- Analyzed complex business requirements and translated them into technical specifications
- Developed and maintained business processes and workflows with focus on BlueCard
- Collaborated with IT teams to implement system enhancements and solutions
- Conducted data analysis to identify trends and opportunities for improvement
Supervisor, Home Blue Card Claims Department
Blue Cross of Idaho
01.2008 - 01.2013
- Supervised a team of claims examiners responsible for processing and resolving complex claims
- Monitored team performance and provided coaching and guidance
- Ensured adherence to quality standards and turnaround time requirements
- Resolved escalated claims and member inquiries
- Trained new employees on company policies, procedures and work ethics
- Supervised and coordinated activities of staff to ensure compliance with established policies, procedures, and standards
- Delegated tasks to team members according to individual strengths
- Worked closely with upper management to develop strategies for improving operational efficiency within the department
- Motivated employees to reach highest professional potential
- Resolved conflicts between team members and departments
- Assessed staff performance on a regular basis, providing feedback and coaching as necessary to improve results
- Set performance goals for staff members and helped teams meet important deadlines
- Notified employees of policy and procedure changes to promote overall compliance
- Conducted employee evaluations and documented overall progress
- Assisted managers with employee recruitment and interviews
- Organized weekly meetings with subordinates to discuss current projects, deadlines, and any other pertinent information
Claims Examiner, Home Blue Card and FEP
Blue Cross of Idaho
06.2004 - 01.2008
- Processed and resolved complex health insurance claims
- Verified eligibility, benefits, and medical necessity
- Communicated with providers and members to obtain and provide information
- Adhered to strict deadlines and accuracy standards
- Handled sensitive information with discretion, ensuring confidentiality of personal and financial details for claimants throughout the claims examination process.
- Utilized analytical skills to evaluate medical bills for accuracy and appropriateness of charges before approving payments as part of the claims process.
- Participated in cross-functional team meetings to address organizational challenges related to claims management and develop solutions collaboratively.
Education
Registered Medical Assistant - Registered Medical Assistant, Certified Phlebotomist
American Institute of Health Technology
Boise, ID01.1993
HIGH SCHOOL -
Borah High School
Boise, ID01.1987
Skills
- Inter-teleprocessing System
- Facets
- Problem-solving
- Critical thinking
- Process improvement
- Documentation and reporting
- Report preparation
- Deadline adherence
- Root-cause analysis
- Regulatory compliance
- Trend forecasting
- Corrective action planning
- Verbal and written communication
- Microsoft office
- MS Excel
- Team collaboration and leadership
Accomplishments
- Regularly met BlueCard goals
- Maintained a BlueCard Score of 100% on the Interplan Scorecard for six months consecutively
- Successfully led 3 Supervisors, 5 Senior Examiners and approximately 40 employees in Benefits Administration
- Collaborated with cross-functional teams for bi-annual BlueCard implementation
- Organized and facilitated team-building activities to improve morale and productivity
References
References available upon request
Notes
- Handled Blue Card appeals through the Blue Squared application, adhering to Blue Card policy.
- Collaborated directly with the Grievance and Appeals Manager to resolve complex claim issues.
- Served as a member of the Grievance and Appeals panel, reviewing incoming appeals, listening to details, and providing recommendations to uphold or overturn decisions.
- Completed Leadership training course
Timeline
Overpayment Analyst
Cambia Health Solutions
06.2023 - 06.2024
Manager, Benefits Administration
Blue Cross of Idaho
06.2014 - 07.2021
Senior Business Analyst
Blue Cross of Idaho
01.2013 - 06.2014
Supervisor, Home Blue Card Claims Department
Blue Cross of Idaho
01.2008 - 01.2013
Claims Examiner, Home Blue Card and FEP
Blue Cross of Idaho
06.2004 - 01.2008
Registered Medical Assistant - Registered Medical Assistant, Certified Phlebotomist
American Institute of Health Technology
HIGH SCHOOL -
Borah High School
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