Roselle Cruz

• Communicate effectively with insurance carriers to secure accurate coverage and benefits data, ensuring meticulous documentation.
• Collaborate with team members to swiftly resolve benefit requests, employing strong problem-solving skills and maintaining responsiveness.
• Record eligibility and benefit details meticulously, ensuring completeness and accuracy in the specified format.
• Foster teamwork across departments, actively engaging in discussions and providing support to swiftly address billing and claims challenges.
• Uphold utmost confidentiality standards for patient and center-related information, complying with all privacy regulations and guidelines diligently.

Negotiate patient's reimbursements from insurance carriers to reduce patient's financial liability and obtain additional funds for the facility (our client).

Review and approve settlement agreements for finalization.

Keep updated on navigating billing software programs within our company and outside insurance carriers.

Review processed payments to ensure adherence to agreed upon negotiations.

Maintain strict confidentially of patients health records.

• Enter new provider data into HR-Payor within departmental standards.
• Input delegated spreadsheet data into HR-Payor as per guidelines.
• Maintain monthly quality score of 97% or higher.
• Update provider demographic details in HR-Payor and CACTUS to match spreadsheet information.
• Review CACTUS data for adherence to entry guidelines.

• Responsible for all inbound shipments, accurate and detailed high-volume inventory count, sorting and recording.
• Provide accounting department with receipts for purchase order processing. Communicate with vendors to report all discrepancies, replacements and returns.
• Post invoices for storage handling.
• Perform weekly Inventory compare on workload management, review and research discrepancies and re-sync inventory systems.

• Receive, document and resolve customer inquiries by using established best practices.
• Educate customers, providers and employers about products and services over the phone.

• Scheduled appointments, verified insurance eligibility, and received and processed requests for medical records.
• Compliant with HIPPA and CMS regulations with all patient identifier information.

• Assisted in investigating claim inquiries/rosters that required secondary escalation due to complexity, immediacy, or project timelines.
• Utilized various systems and analytical skills to research claims denials that were perceived inappropriate or any other claims-related concerns and inquiries.
• Communicated the investigation results to the provider/ designee and advised on the steps for the plan of correction.
• Facilitated collaboration with various departments to ensure successful claim resolution.

• Investigated and responded to written or verbal appeals and grievances submitted by members and providers in accordance with Contract Benefits, CMS, and DOH regulations.
• Determined appropriate action and presented cases for review.

• Audited the job performance of Customer Service Representatives. Reviewed telephone contact calls to ensure accuracy in communication.
• Documented audit findings and provided recommendations for corrective action.
• Facilitated training sessions and assisted in training material updates as needed.

• Analyzed daily call center reports; identifying trends to implement process improvements as needed.
• Handled member/provider issues that required follow up and/or intervention by a senior staff member and determined a resolution at the time of the call to ensure the highest service possible.
• Issued Explanation of Payment and Explanation of Benefits when requested.
• Updated and maintained HLNKS call backs spreadsheet.
• Participated in inter and intra department project teams; worked with others toward shared goals.
• Oversaw the Call Center when supervisors were unavailable.

• Responded to member and provider inquires and requests concerning benefits, claims and complaints.
• Complied with minimum requirements and documented calls in phone log.
• Adhere to all established policies and procedures within organization in communicating patient information internally and externally.