Summary
Overview
Work History
Education
Skills
Personal Information
Languages
Timeline

Wanda Cruz

Blue Springs,MO

Summary

Experienced Provider disputes Representative successful at managing high caseloads in fast-paced environments. Organized, driven and adaptable with excellent planning and problem-solving abilities. Offering 24 years of experience, and willingness to take on any challenge. Highly trained to to handle various office tasks with undeniable ease.

Overview

28
28
years of professional experience

Work History

Provider Disputes Representative

GEHA
06.2023 - Current
  • Responds to provider disputes, grievances and correspondence received via mail and email correspondence
  • Reviews inquiries received in department queues
  • Appropriately identifies correspondence to determine the correct course of action to respond or forward recommendation to manager for review and/or advisement
  • Investigates complex grievances and disputes in accordance with regulatory requirements
  • Utilizes guidelines and review tools to conduct extensive research and analyze appeal issue(s), pertinent claims, internal policies, and medical records
  • Research claim processing logic to verify accuracy of claim payment, member eligibility data, and billing/payment status
  • Research Brochure Plan pertinent to the claim to determine accuracy/appropriateness of benefit/administrative determination
  • Understands and maintains knowledge of provider networks, medical/dental management processes, claim processes and the company's internal business processes
  • Accepts accountability to ensure complaint/dispute is handled within established timeframe to meet company and regulatory requirements
  • Contacts provider for additional information needed to process release of a claim
  • Documents detailed information received in dedicated Notes tools
  • Identifies trends and emerging issues and gives input on potential solutions
  • Manages/assists with incoming correspondence and routing to internal inboxes for processing.

Medical Claims Processor

GEHA
06.2019 - 05.2023
  • Managed large volume of medical claims on a daily basis
  • Reviewed provider coding information to report services and verify correctness
  • Paid or denied medical claims based upon established claims processing criteria
  • Used administrative guidelines as resource or to answer questions when processing medical claims
  • Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations
  • Responded to correspondence from insurance companies
  • Researched and resolved complex medical claims issues to support timely processing
  • Verified patient insurance coverage and benefits for medical claims
  • Identified and resolved discrepancies between patient information and claims data
  • Evaluated medical claims for accuracy and completeness and researched missing data
  • Communicated verification and authorization status updates with Care Management department to facilitate decision-making for patient admissions and insurance coverage.

Inbound Call Center Representative

GEHA
04.2018 - 06.2019
  • Utilizes effective communication and interpersonal skills via all avenues of communication adhering to company standards
  • Provides informative breakdown of medical insurance benefits and uses company tools to answer medical claim questions to members and providers
  • Works independently with little periodic supervision
  • Can self-monitor performance and quickly adjust to changing adherence policy
  • Flexible with task changes, responsibilities, and special projects
  • Uses professionalism and empathy when communicating and preparing correspondence via call, email, and fax
  • Coordinates with other departments Enrollment, Cost Recovery, Care Management, Dental and contracted vendors such as OrthoNet and Evicore to accomplish tasks and answer pressing inquiries and offering solutions
  • Detail oriented and accurate navigating multiple GEHA systems to review authorizations, appeals, claims, and medical records
  • Submitting data entry notations or service tickets to resolve discrepancies
  • Uses strong analytical and problem-solving skills to troubleshoot day to day calls verifying health documentation submission
  • Adheres to company policy guidelines instilled by GEHA and privacy laws by HIPAA
  • Assisted with Peer-to-Peer coaching.
  • Answered phone with friendly greeting to create positive inbound calling experience for customers.
  • Improved first-call resolution rates by effectively utilizing resources and available tools.
  • Maintained high-quality service standards for all inbound calls, ensuring prompt and accurate assistance.

Accounts Receivable Specialist

AT&T
03.2012 - 03.2018
  • Negotiated payment arrangements with customers to establish timely receipt of payments.
  • Contributed to a positive work environment by working closely with colleagues across departments to ensure efficient information exchange and collaboration on financial matters.
  • Followed up overdue payments and payment plans from clients to establish good cash flow.
  • Improved customer satisfaction by providing prompt, courteous service when addressing billing concerns or inquiries.
  • Collaborated with sales teams to address billing discrepancies and resolve client disputes promptly.
  • Trained new team members on company policies, software systems, and effective accounts receivable practices for seamless integration into the role.
  • • Demonstrated expertise handling escalated customer calls from inbound representatives when customers required manager assistance.
  • • Met company standards to employ the necessary techniques to defuse an abusive or irate customer while working towards a resolution.
  • • Accurately and securely processed payments and credits on customer's accounts to ensure continuous service. Displayed a positive leadership role and good time management skills while following office procedure and handling calls to completion while containing the calls at the lowest level.
  • • Assisted with the development of the call center's operations, quality and training processes.

Customer Service Representative

AT&T
07.1996 - 03.2012
  • Handled customer inquiries and suggestions courteously and professionally.
  • Managed high-stress situations effectively, maintaining professionalism under pressure while resolving disputes or conflicts.
  • Actively listened to customers, handled concerns quickly and escalated major issues to supervisor.
  • Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
  • Answered customer telephone calls promptly to avoid on-hold wait times.
  • Updated account information to maintain customer records.
  • Conducted several Initial Training classes for newly hired Service representatives.
  • Processed customer service orders promptly to increase customer satisfaction.
  • Participated in team meetings and training sessions to stay informed about product updates and changes.
  • Contributed to sales growth by upselling products and services based on individual customer requirements.

Education

General Studies -

Fort Osage High School, Independence, MO
05.1992

Skills

  • Excellent conflict resolution abilities
  • Adherence to high customer service standards
  • Organizational and time management skills
  • Software
  • Team-oriented and dependable
  • Fluent in Spanish
  • Call Handling Techniques
  • Problem-solving skills
  • Verbal and written communication
  • Interpersonal Skills
  • Training experience
  • Performance Metrics

Personal Information

Title: Provider Disputes Representative

Languages

Spanish
Native or Bilingual

Timeline

Provider Disputes Representative - GEHA
06.2023 - Current
Medical Claims Processor - GEHA
06.2019 - 05.2023
Inbound Call Center Representative - GEHA
04.2018 - 06.2019
Accounts Receivable Specialist - AT&T
03.2012 - 03.2018
Customer Service Representative - AT&T
07.1996 - 03.2012
Fort Osage High School - General Studies,

Similar Profiles

CREATE PROFILE
Wanda Cruz