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
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