Laura Cruz
Litchfield Park,AZ
Summary
Dedicated professional with over 26 years of experience in the Healthcare Insurance industry, particularly within the Blue Plan association. Proven track record as a successful remote worker for 23 years across various roles and departments, demonstrating adaptability and versatility. Expertise in Payment Integrity ensures accurate claims processing while safeguarding the interests of members and groups. Results-driven management professional recognized for leading teams toward operational excellence through strategic planning and process improvement, fostering a culture of accountability and collaboration. Strong communication and organizational skills contribute to creating productive work environments, driving project success, and achieving measurable outcomes that enhance overall organizational efficiency.
Overview
27
27
years of professional experience
Work History
Manager Payment Integrity Operations
Blue Cross of Idaho
10.2021 - 08.2024
- I am responsible for the management and oversight of the Payment Integrity department operational processes related to identification and resolution of claims billing and claims payment waste, abuse, and errors. Programs include provider coding education, claim auditing, overpayment recovery activities, data mining, subrogation, third party liability (TPL), coordination of benefits (COB), Vendor, Self-Funded Group & Blue Plan Invoicing, and Payment Integrity program reporting.
- Activities include:
- Collaborating with other departments to identify root cause of overpayments and inaccuracies.
- Direct, plan and execute internal and external efficiency and process improvement solutions.
- Manage vendor programs for the payment integrity area to include identification of new vendors, proposal and selection process, contract negotiation, on-boarding/off-boarding, relationship, performance, and invoicing.
- Develop and interpret policies, procedures, service standards, and workflows to support the consistent application of practices across the functional area and compliance with regulations.
- Ensure that department milestones/goals are met.
- Ensure effective workflows, maximize system efficiencies, monitor quality performance measures, and confirm appropriate completion of work assignments.
- Provides guidance, counseling, and continuing education to staff. Select, develop, coach, mentor, and assess performance of staff.
- In collaboration with senior leadership, design, develop and implement focused functional area strategies.
- 9 direct reports, 7 indirect reports
- Led cross-functional teams to enhance operational efficiency and service delivery.
- Developed and implemented strategic initiatives to improve member engagement and satisfaction.
- Oversaw budget management processes, ensuring alignment with organizational goals and financial targets.
- Mentored staff to foster professional growth and improve team performance metrics.
- Analyzed data trends to inform decision-making and optimize resource allocation strategies.
- Collaborated with stakeholders to streamline workflows and enhance service offerings in health programs.
- Established key performance indicators to measure success of operational strategies across departments.
- Facilitated training sessions on best practices, promoting a culture of continuous improvement within the organization.
- Developed and maintained relationships with customers and suppliers through account development.
- Negotiated favorable terms with suppliers, cutting operational costs while maintaining quality of service.
- Coordinated with IT department to upgrade technology infrastructure, enhancing operational efficiency and data security.
Retired
Regence BCBS
04.2021 - 10.2021
Supervisor Payment Integrity Support Services
Regence BCBS
04.2018 - 04.2021
- I was Supervisor of Payment Integrity Support Services which included a team of 2 Data Reporting Analyst SRs and 1 Corporate Research Analyst SR. I lead our PI Enablement team in building and publishing Tableau Dashboards, creating monthly vendor invoices with detailed reporting, and performing market analysis and benchmarking research.
- I lead several Strategic Initiative projects that expand across several business areas. I have broadened my Leadership skills through completing the Introduction to Management, Situational Leadership, Transformative Leadership, and participating in the 50/50 Talent Development program in 2018.
- I supported the Vendor Management department working directly with current and future vendors. I have documented the Pre-Boarding, On-Boarding, and Off-Boarding processes for Vendors. I review/advise on Vendor contracting, work with DTS to clarify requirements for building vendor data extracts, answer data related questions and resolve any data issues that may occur. I have an active role in the scorecard development and performance reviews of our overpayment identification Vendors. Helping to verify they are adhering to their contracted performance agreements and meeting our quality standards.
- I have developed my Project Management skills receiving a Lean Six Sigma Greenbelt certification and a Project Management Qualification certification.
- A few examples of projects I have led are:
- 50/50 Strategic Initiative Payment Integrity Data Enablement.
- The Automate COB Loads project where I lead the COB Carrier ID clean-up efforts between the COB Investigation teams and the Business Support Services team.
- The Automation of daily data files received from vendors through SFTP.
- I identified inefficiency in our monthly vendor invoicing process and oversaw the creation and implementation of the new process.
- Implemented our new invoicing process to other Blue Plans for 3rd Party Vendor fees from Overpayment Identification on HOST ITS claims
Data Reporting Analyst SR
Regence BCBS
02.2016 - 04.2018
Data Reporting Analyst
Regence BCBS
09.2015 - 02.2016
Data Reporting Analyst Assoc
Regence BCBS
12.2013 - 09.2015
Member Service Lead (COB Investigation)
Regence BCBS
05.2012 - 12.2013
Claims Service Specialist I & II
Regence BCBS
04.2007 - 05.2012
Claims Service Analyst III
Regence BCBS
04.2002 - 04.2007
Claims Refund Adjustment Analyst
Regence BCBS
01.2001 - 04.2002
Data Entry, Customer Service, Computer Operations, Claims Processing
Regence BCBS
01.1998 - 01.2001
Education
Project Management Qualified -
Management And Strategy Institute
Online09.2017
Lean Six Sigma Greenbelt -
Six Sigma Global Institute
Online11.2016
Mount Vernon Beauty School
Mt. Vernon, WA01.1987
Mount Vernon High School
Mt. Vernon, WA01.1987
Kiona-Benton High School
Benton City, WA01.1985
Skills
- Effective leadership
- Organizational strategy development
- Analytical problem resolution
- Operational efficiency enhancement
- Supplier relationship management
- Payment integrity management
- Effective contract negotiation
- Continuous process evaluation
- Interdepartmental teamwork
- Effectiveness analysis
- Expense tracking and analysis
- Client relationship management
Timeline
Manager Payment Integrity Operations
Blue Cross of Idaho
10.2021 - 08.2024
Retired
Regence BCBS
04.2021 - 10.2021
Supervisor Payment Integrity Support Services
Regence BCBS
04.2018 - 04.2021
Data Reporting Analyst SR
Regence BCBS
02.2016 - 04.2018
Data Reporting Analyst
Regence BCBS
09.2015 - 02.2016
Data Reporting Analyst Assoc
Regence BCBS
12.2013 - 09.2015
Member Service Lead (COB Investigation)
Regence BCBS
05.2012 - 12.2013
Claims Service Specialist I & II
Regence BCBS
04.2007 - 05.2012
Claims Service Analyst III
Regence BCBS
04.2002 - 04.2007
Claims Refund Adjustment Analyst
Regence BCBS
01.2001 - 04.2002
Data Entry, Customer Service, Computer Operations, Claims Processing
Regence BCBS
01.1998 - 01.2001
Project Management Qualified -
Management And Strategy Institute
Lean Six Sigma Greenbelt -
Six Sigma Global Institute
Mount Vernon Beauty School
Mount Vernon High School
Kiona-Benton High School
ACTIVITIES
- I have expanded my Leadership skills through completing the following trainings:
- BCI Culture Development
- Introduction to Management
- Situational Leadership
- Transformative Leadership
- Participating in the 50/50 Talent Development program in 2018.