Maria De Pilar Lopez
Miami,FL
Overview
4
4
years of professional experience
Work History
Direct Contracting Associate
Oscar Health Insurance
Miami , FL
08.2021 - Current
- Executed low unit cost contracts to benefit the company and Its members
- Build adequate and salable networks for optimal member experiences
- Provide excellent service to partners ensuring positive provider experiences
- Ensure strong partnerships with transparent communication and expectations regarding contracting processes, policies and procedures
- Asses and build the provider network to ensure regulatory adequacy and member experience while meeting a salability target >90%
Supervisor
Kforce
Miami , FL
03.2021 - 07.2021
- Supervised team of 35 agents, ensuring adherence to quality standards, deadlines, and proper procedures
- Collected and analyzed call center statistics, costs and customer service metrics.
- Prepared reports to assist business leaders with key decision making and strategic operational planning.
- Perform operational tasks to assure project and program service level requirements and goals are met, including analyzing direct reports’ quality performance and trending call types
- Interpret, apply and demonstrate understanding of key indicators in order to make better business decisions
Case Investigator
Kforce
Miami , FL
08.2019 - 03.2021
- Gather disease information from diagnosed individuals and assess disease symptomatology
- Provide contacts with approved information about quarantine/isolation procedures, and if appropriate, refer them to testing according to protocol and/or to COVID-19 social resources
- Coordinated with public health and local facilities to support isolation and quarantine of individuals.
- High volume outbound cold calling, averaging 85-120 calls per day
Medical Claims Auditor
Healthcare Retroactive Audits
Miami , Florida
08.2019 - 08.2020
- Analyze payment trends within large data sets
- Initiated loss containment by conducting thorough audits and data mining.
- Reviewed insurance claims and member eligibility to determine underpayment trends and noncompliance issues.
- Draft and submit appeals for claims denied incorrectly based on pre-authorization and medical necessity
- Recovered $1.2 million USD in underpaid and improperly denied claims
Medical Biller and Auditor
Southeast Physician Associates
Miami , FL
07.2017 - 04.2018
- Audit medical record documentation to identify under coded and up coded services, unreported HEDIS measures and unreported chronic conditions (MRA)
- Prepare reports of findings and meet with providers to provide education and training on accurate coding practices/compliance issues
- Audited an average of 75 complex and problematic accounts daily
- Tracked delinquencies and create statistical spreadsheets to keep management updated on status of accounts
- Thorough knowledge of electronic billing protocols & ability to successfully resolve problems with patients, Medicaid, Medicare, managed care and private insurers
Education
Associate of Science - Billing and Coding
Florida Technical College
Cutler Bay, FL09.2017
Skills
- Critical Thinking
- Billing and Collections Procedures
- Legal Standards
- Discrepancy Resolution
- Categorizing and Classification
- Revenue Operations
Timeline
Direct Contracting Associate
Oscar Health Insurance
08.2021 - Current
Supervisor
Kforce
03.2021 - 07.2021
Medical Claims Auditor
Healthcare Retroactive Audits
08.2019 - 08.2020
Case Investigator
Kforce
08.2019 - 03.2021
Medical Biller and Auditor
Southeast Physician Associates
07.2017 - 04.2018
Associate of Science - Billing and Coding
Florida Technical College
Similar Profiles
Michelle DeanMichelle Dean
Operations Team Leader at Oscar Health InsuranceOperations Team Leader at Oscar Health Insurance
Angelica ThomasAngelica Thomas
Clinical Care Coordinator at Oscar Health InsuranceClinical Care Coordinator at Oscar Health Insurance
Christian BankesChristian Bankes
Senior Analyst, SIU Investigator at Oscar Health InsuranceSenior Analyst, SIU Investigator at Oscar Health Insurance