NYELL CRUZ
Henrico,VA
Summary
Experienced and enthusiastic Consultant with track record of success across wide range of industries. Possesses exceptional interpersonal, problem-solving and analytical skills to provide advice and expertise to client organizations improving business performance. Experienced in all aspects of operations, strategy and finance.
Overview
7
7
years of professional experience
Work History
CLININICAL CONSULTANT
Health Care Support, CVS HEALTH
06.2022 - Current
- Coordinating the PA System implementations by meeting with internal and external partners to gather and document client requirements, state regulations, and Caremark Prior
- Authorization department’s needs
- Working withinCAS Admin tobuild client setup within the PA system, aswell astesting/quality checking to ensure client buildouts meet client and operational needs to assure teams are within compliance
- Creates, maintains, and communicates PA System and process documentation
- Provides ongoing continued support for internal and external partners such as facilitating meetings, projects, and process implementations
- Acting as Liaison between PA Operations, PA Admin, Client users, and account management
- Builds and sustains working relationships with Operation leaders, PA Admin leaders, IT contacts, client contacts, and account team members to fully support our client’s needs
- Working closely with IT, by submitting BSR requests based on client, operations, and regulatory requirements
- Participating in CAS Release User Acceptance Testing and coordinating Beta testing
- Assist other colleagues in the various aspects required to function effectively in their roles
- Facilitate Prior Authorization System demos to internal and external CAS users and partners
- Delivered outstanding service to clients to maintain and extend relationship for future business opportunities.
- Supported clients with business analysis, documentation and data modeling.
- Liaised with customers, management and sales team to better understand customer needs and recommend appropriate solutions.
- Collected, arranged and input information into database system.
- Developed service plans in consultation with clients, and performed follow-ups assessing quantity and quality of services.
- Developed strategic component development plans to support future projects.
MEMBER SERVICE ADVOCATE SUPERVISOR
ANTHEM BCBS
03.2021 - 03.2022
- Guide members and providers with their healthcare needs by explaining benefits, solving claim concerns, helping find a doctor via telephone calls, online chats, or e-mails.
- Partner internally to create a seamless experience for our customers and resolve potential issues.
- Proactively resolving our members and/or providers questions and concerns using computer- based resources to find answers.
- Multi-tasking, navigating multiple computer applications and working efficiently while communicating and serving the customer.
- Researches and analyzes data to address customer service issues.
- Provides external and internal customers with requested information.
- Setting goals for performance and deadlines in ways that comply with company’s plan and vision.
- Monitor employee productivity and provide constructive feedback and coaching.
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
- Handled customer complaints, resolved issues and adjusted policies to meet changing needs.
- Maintained compliance with company policies, objectives and communication goals.
MEMBER SERVICE ADVOCATE REPRESENTATIVE
CONDUENT
09.2019 - 03.2021
- Processed providers authorization requests via fax or phone for medical procedures, durable medical equipment, outpatient surgery etc
- Resolved complex escalated internal and external operational questions
- Provided operational services, assisted, and coordinated for one or more of the day-to-day Medicaid operation functions
- Managed non-clinical needs of members with co morbities, disabilities, to ensure the highest quality of care was rendered to our member
- Educated and assisted members with questions related to benefits, appeals
- Collaborated with Registered Nurses and Medical Directors of the organization with program policies, business processes and system changes to ensure the state requirements of the Plan were met
- Resolved inquiries from member and providers, while exceeding quality, productivity departmental goals.
- Scanned documents and saved in database to keep records of essential organizational information.
- Corrected data entry errors to prevent later issues such as duplication or data degradation.
- Verified accuracy of data before transcribing.
- Organized, sorted and checked input data against original documents.
HUMAN RESOURCES INTERNSHIP
MONAHAN HEALTH CARE
07.2016 - 09.2019
- Plan and manage recruitment and selection of staff
- Identify and manage training and development needs for employees
- Administered HR policies and procedures
- Handle employee complaints, grievances, and disputes
- Maintain the human resource information system and employee database
- Maintain knowledge of legal requirements and government reporting regulations affecting HR functions
- Supported efforts to optimize employee engagement, diversity and inclusion to enhance performance management and retention.
- Prepared monthly, weekly and daily logs using Microsoft Office Suite.
Education
Bachelor Of Applied Science - Human Resource Management
BRYANT AND STRATTON COLLEGE
Richmond, VA04.2022
Associate Of Applied Science - Early Childhood Education
J. SERGEANT REYNOLDS COMMUNITY COLLEGE
RICHMOND, VA 06.2018
Skills
- Project Analysis
- Issue Resolution
- Research and Development
- Client Engagement
- Honesty and Integrity
- Analytical Thinking
- Team Leadership
- MS Office
- Client Relationships
- Financial Planning
- Website Navigation
- Troubleshoot Service Issues
- Leadership
- Onboarding Understanding
- New Hire Processes
- Clinical Care
- Process Update Procedures
- Business Solutions
- Creative Thinking
- Patient Health Information Access
- Information Updates
- Customer Feedback
- Constructive Feedback
- Microsoft Office
- Team Meetings
- Strategic Initiatives
- Production Goals
- Project Requirements
Timeline
CLININICAL CONSULTANT
Health Care Support, CVS HEALTH
06.2022 - Current
MEMBER SERVICE ADVOCATE SUPERVISOR
ANTHEM BCBS
03.2021 - 03.2022
MEMBER SERVICE ADVOCATE REPRESENTATIVE
CONDUENT
09.2019 - 03.2021
HUMAN RESOURCES INTERNSHIP
MONAHAN HEALTH CARE
07.2016 - 09.2019
Bachelor Of Applied Science - Human Resource Management
BRYANT AND STRATTON COLLEGE
Associate Of Applied Science - Early Childhood Education
J. SERGEANT REYNOLDS COMMUNITY COLLEGE
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