Cesar R Rosario Cruz

Conduct high-level review and analysis of complex Medicare, Medicaid, and commercial claims to ensure coding, medical necessity, and regulatory compliance; reduced rework by 15% and optimized claims cycle efficiency.

Evaluated claims for eligibility, coding accuracy, and medical necessity to prevent improper payments and resolve provider billing disputes across payer networks.

Reviewed claims for accuracy, duplication, and compliance; supported FWA investigations and generated audit reports to inform corrective actions.

Supervised 15+ agents, designed SOPs to improve call handling and dispute resolution, and drove a 10% improvement in customer satisfaction through training and workflow redesign.

Grade: 3.85

Completed a Master's degree in Healthcare Services Management and Evaluation with a focus on healthcare management, outcomes evaluation, and payment integrity practices.

Grade: 3.33

Completed a Bachelor's degree in Nursing with coursework in general science and clinical nursing practice, supporting clinical and claims review expertise.