Lisa Garcia
Arlington,TX
Summary
Dynamic Appeals Analyst with CVS Health Corporation, skilled in claims analysis and regulatory compliance. Proven ability to resolve complex issues through effective problem-solving and decision-making. Recognized for enhancing appeal processes and maintaining organized case records, ensuring adherence to healthcare coding standards while delivering exceptional service to clients.
Overview
13
13
years of professional experience
Work History
Appeals Analyst
CVS HEALTH CORPORATION
Arlington, TX
05.2025 - 10.2025
- Reviewed appeals for accuracy and compliance with company policies.
- Collaborated with healthcare providers to gather necessary documentation.
- Analyzed claims data to identify trends and potential issues.
- Maintained organized records of appeal cases and outcomes.
- Assisted in training new analysts on appeal processes and systems.
- Researched regulatory guidelines to ensure adherence in appeals decisions.
- Supported management by preparing reports on appeal activity and findings.
- Reviewed patients' insurance coverage, deductibles, possible insurance carrier payments and remaining balances not covered under policies.
- Managed denials, late payments, extensions and other special circumstances by following up with relevant parties.
- Maintained accurate records of all activities related to the appeals process.
- Assisted patients with insurance questions by studying benefits.
- Compiled data for appeals cases utilizing Microsoft Office Suite products.
- Interpreted complex rules, regulations, policies and procedures related to appeals.
- Advised management on best practices for resolving difficult claims disputes.
- Participated in training sessions designed to keep abreast of new laws or regulations affecting the appeals process.
- Conducted research on evidence submitted in support of appeals.
- Analyzed and evaluated appeals to ensure compliance with applicable laws, regulations, policies and procedures.
- Provided guidance and assistance to other departments regarding the appeals process.
- Developed strategies for efficient resolution of appeals cases.
- Drafted correspondence responding to inquiries from internal and external stakeholders regarding the status of individual claims or general policy questions.
- Coordinated with various departments when additional information was required for a successful resolution of an appeal.
- Actively monitored progress on pending appeal cases ensuring timely completion of tasks associated with each claim dispute resolution.
- Attended meetings with management staff concerning policy changes impacting the appeals process.
- Reviewed documents for accuracy and completeness prior to processing appeals.
- Researched relevant case law pertaining to specific issues raised in an appeal.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Delivered exceptional customer service to clients by communicating information and actively listening to concerns.
- Investigated potentially fraudulent claims with focus on thoroughness, quality, and cost control.
Claims Help Desk
CVS HEALTH CORPORATION
Arlington, TX
05.2017 - 08.2020
- Completed day-to-day duties accurately and efficiently.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
- Promoted high customer satisfaction by resolving problems with knowledgeable and friendly service.
- Prioritized and organized tasks to efficiently accomplish service goals.
- Identified needs of customers promptly and efficiently.
- Assisted with customer requests and answered questions to improve satisfaction.
- Collaborated closely with team members to achieve project objectives and meet deadlines.
- Worked with cross-functional teams to achieve goals.
- Maintained updated knowledge through continuing education and advanced training.
- Provided support and guidance to colleagues to maintain a collaborative work environment.
- Exceeded customer satisfaction by finding creative solutions to problems.
- Recognized by management for providing exceptional customer service.
- Utilized advanced technical skills and expertise to troubleshoot complex problems and implement solutions.
- Conducted comprehensive research and data analysis to support strategic planning and informed decision-making.
- Utilized various software and tools to streamline processes and optimize performance.
Claims Processor
CVS HEALTH CORPORATION
Arlington, TX
07.2012 - 05.2017
- Processed insurance claims by reviewing submitted documents and verifying information.
- Evaluated policy coverage and determined claim eligibility based on guidelines.
- Maintained organized records of processed claims within company systems.
- Assisted in training new staff on company procedures and claims processing tools.
- Adhered to compliance standards while handling sensitive client information securely.
- Processed a high volume of incoming claims in accordance with established policies and procedures.
- Verified claim data correctness in preparation for processing.
- Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
- Adhered to all applicable laws, regulations, and company standards while processing claims.
- Reviewed and verified insurance policy information to assess coverage and determine appropriate claims processing procedures.
- Analyzed contracts and claim systems to apply appropriate benefit amounts.
- Conducted and documented comprehensive investigations to negotiate settlements or deny claims.
- Provided technical guidance and training to new staff members regarding claim processing procedures.
- Maintained accurate records of all processed claims in accordance with departmental requirements.
- Coordinated benefits with medical insurance plans and Medicare providers.
- Evaluated the validity of assigned claims by verifying that services are medically necessary according to established guidelines.
- Analyzed and evaluated claim forms, medical reports, bills, and other documents to ensure accuracy of data.
- Resolved complex issues associated with denied or underpaid claims through negotiation with payers.
- Documented decisions on each claim based on research findings and applicable benefit plans.
- Identified trends in denials or rejections due to incorrect coding or billing practices by providers.
- Researched discrepancies between submitted documentation and actual records to identify errors or omissions.
- Applied knowledge of coding systems such as CPT-4 and HCPCS codes for proper reimbursement.
- Performed additional duties as requested by management team.
- Reviewed history records to determine benefit eligibility for services.
- Corresponded with providers regarding any missing or incomplete documentation needed for successful adjudication of claims.
- Performed quality assurance reviews on completed work to ensure compliance with standards.
- Reconciled payment discrepancies between provider statements and remittance advice from payers.
- Participated in meetings with internal stakeholders regarding changes in policy, procedure, technology.
- Updated job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations .
- Participated in audits of claims files to ensure adherence to company policies.
- Kept abreast of changes in insurance regulations and policies affecting claims processing.
- Assisted in developing and implementing process improvements to reduce processing times.
- Responded to external audits by providing requested claims documentation and explanations.
- Managed workload to meet or exceed productivity and quality standards.
- Followed up on pending claims and resolved issues delaying processing.
- Identified and flagged suspicious claims for further investigation.
- Utilized claims processing software to streamline workflow and increase efficiency.
- Coordinated with healthcare providers to obtain missing information or clarification on claims.
- Adhered to state and federal regulations regarding insurance claims processing.
- Reviewed and processed incoming insurance claims to ensure accuracy and completeness.
- Calculated benefits due based on policy terms and claim information.
- Maintained confidentiality of policyholder information in compliance with HIPAA regulations.
- Entered claim information accurately into database systems.
- Checked documentation for appropriate coding, catching errors and making revisions.
- Prepared and reviewed insurance-claim forms and related documents for completeness.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
- Coordinated and planned investigations of claims to confirm compensability and coverage.
- Modified and updated existing policies and claims to reflect change in beneficiary, amount of coverage or type of insurance.
- Organized information by using spreadsheets, databases or word processing applications.
- Handled modification and updating of policies.
- Signed payment approvals accepted claims.
Education
High School Diploma -
South Grand Prairie
Grand Prairie05-1996
Health Care Administration
Southern New Hampshire University
Hooksett, NHEducation
Tarrant County College
Fort Worth, TXSkills
- Claims analysis and appeals processing
- Regulatory compliance
- Research and time management
- Multitasking skills
- Case management
- Problem-solving abilities
- Healthcare common procedures coding system (HCPCS)
- Decision-making skills
References
References available upon request.
Timeline
Appeals Analyst
CVS HEALTH CORPORATION
05.2025 - 10.2025
Claims Help Desk
CVS HEALTH CORPORATION
05.2017 - 08.2020
Claims Processor
CVS HEALTH CORPORATION
07.2012 - 05.2017
High School Diploma -
South Grand Prairie
Health Care Administration
Southern New Hampshire University
Education
Tarrant County College
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