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Skills

  • HIPAA compliance
  • Problem resolution
  • Conflict resolution
  • Project organization
  • Workers’ compensation claims
  • Project management
  • Business operations
  • Property adjusting
  • Claims file management processes
  • Appeals process management

Work Experiences

  • Achieved resolution within 18 months.
  • Reduced loss ratios by processing claims in a fair and timely manner.
  • Followed company and insurance client guidelines, resulting in initiative in claim processes, estimate writing, and claim closure.
  • Used Salesforce to compile data gathered from various sources.
  • Achieved quicker resolutions for priority clients.
  • Achieved resolutions within 18 months.
  • Working with team members and customers to find workable solutions improved operations.
  • Kept my process knowledge up to date by doing client relations and team leadership.
  • Achieved Employee of the Year for maintaining a 26% first-call resolution rate in claim appeals across a one year-month period.
  • Achieved a 23% success rate.

Summaries

  • Achieved a 54% decrease in appeal processing delays.
  • Looking forward to taking on a new challenge with a successful team.
  • Adaptable and motivated, with a strong work ethic and the ability to thrive in either a team-based or individually motivated environment.
  • Achieved high accuracy and pace.
  • Claim Collections Appeal Representative is a hardworking and dependable Claim Collections Appeal Representative who excels at process improvement and strategic planning.
  • Accomplished in reducing claim resolution times by 40% through the introduction of streamlined communication practices and efficient processes.
  • Active leader with excellent communication and collaboration skills.
  • Accounting and Finance student seeking hands-on experience through an internship in stakeholder engagement.
  • Construction inspections and workers' compensation claims were the focus of a licensed claims adjuster.
  • Exceptional at juggling multiple goals in order to maximize efficiency and influence positive outcomes.

Accomplishments

  • Reduced overall appeal processing time by 32% through the implementation of automated workflows within the Jira system.
  • Analyzed and implemented change requests to existing processes, increasing team accuracy rate by 80% and reducing claim turnaround time.
  • Successfully recovered $61,000 in payments through effective collections on behalf of clients navigating the appeals process.
  • Utilized Salesforce to manage case loads exceeding 4 claims per day, resulting in a 78% reduction in claim resolution times.
  • Collaborated with provider networks to resolve high-value claims, securing reimbursement on 3 multi-million-dollar claims.
  • Consistently met or exceeded escalation KPIs by resolving 7 high-priority appeals weekly while minimizing legal exposure for the company.
  • Implemented process improvements in appeals documentation, reducing errors and improving first-pass approval rates by 27%.
  • Conducted thorough investigations of denied claims, overturning decisions on 18% of appealed cases, saving clients over $145,000.
  • Leveraged Power BI to build customized reporting tools that improved visibility into appeals processes and identified areas for optimization.
  • Contributed to departmental goal of reducing claim denial rates from 28% to 20% by enforcing more rigorous pre-submission checks.

Affiliations

  • Attendee, Annual HFMA Conference, 2024
  • Participant, AHIMA Denials Management Certification
  • Volunteer, Healthcare Claims and Appeals Consulting Initiative, Raleigh
  • Mentor, Healthcare Appeals Professionals Association Coaching Program, 2017
  • Attendee, Denials Management & Claims Optimization Workshop, 2016
  • Participant, Claims and Risk Management Continuing Education Program, Vantage
  • Participant, Advanced Claims Appeals Training Program at Ironclad Systems
  • Certified Medical Office Manager (CMOM), Practice Management Institute
  • Affiliate Member, Healthcare Financial Management Association (HFMA)
  • Certified Compliance Professional (CCP), 2024

Certifications

  • Certified Managed Care Professional (CMCP), NAMCP
  • Electronic Health Record Specialist Certification (CEHRS) - procedure
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Patient Account Representative (CPAR) – AAHAM
  • American Academy of Financial Management (AAFM)
  • Apple Certified Associate (ACA)
  • Certification in Healthcare Customer Service, Summit Group
  • Health Data Analyst Certification (CHDA), AHIMA
  • Certified Case Manager (CCM) - system
  • Certified Healthcare Access Associate (CHAA) method

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