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Skills

  • Hardware evaluation
  • Communications
  • Conflict resolution
  • Rules of evidence
  • User interface understanding
  • Insurance policy coverage knowledge
  • Cross-functional team leadership
  • Relationship development
  • Data Management
  • Underwriting knowledge

Work Experiences

  • Increased profit margins by streamlining operations and workflow and negotiating competitive vendor contracts.
  • Achieved 40% audit approval rating.
  • Created a new employee evaluation process that resulted in significant performance improvements.
  • Saved money by developing functional solutions to metric problems.
  • Used Tableau to compile data gathered from various sources.
  • Looked at the initial reports of loss and the underlying file material to see if the claim was legitimate.
  • Assisted various business groups with document organization and dissemination during acquisitions.
  • Worked with others to brainstorm new category possibilities.
  • Was able to effectively respond to customer requests via phone and email, as well as answer questions and inquiries.
  • Workday was delivered to customer locations by me.

Summaries

  • Reliable and trustworthy.
  • Knowledgable in a variety of design and testing methodologies.
  • Healthcare student seeking hands-on experience through an internship in stakeholder engagement.
  • Medical Claims Examiner with cross-functional collaboration and budget management abilities.
  • Criminal investigation, insurance fraud, and surveillance are all part of his background.
  • Working with Agile and Scrum methodologies to meet project milestones within specified timeframes is a strong suit.
  • Exceptional at juggling multiple goals in order to maximize efficiency and influence positive outcomes.
  • Team leadership in framework settings and workflow optimization in performance reporting settings.
  • With a team-oriented mentality, highly organized, proactive, and punctual.
  • Dynamic communicator who consistently outperforms company goals and expectations.

Accomplishments

  • Effectively overturned 72% of appealed claims saving the company $3 in potential payouts and reducing legal disputes.
  • Orchestrated department-wide initiative that resulted in standardized claim examination procedures, improving team efficiency and reducing error rates by 47%.
  • Prevented HIPAA breaches by ensuring all claims documentation met confidentiality and security standards, leading to zero audit findings for 2021.
  • Collaborated with IT to implement an optimized claims adjudication platform, reducing manual review time by 46%.
  • Completed quarterly claims audits that ensured compliance with internal policies and external regulations, earning initiative accreditation.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Initiated process improvements in tracking system, which led to a 10-day reduction in the turnaround time for processing claims.
  • Developed and implemented training program for new hires on claims adjudication best practices, contributing to employee retention improvement by 22%.
  • Increased sales 18% over 6 months.
  • Developed a comprehensive performance dashboard to monitor claims throughput and accuracy, improving transparency and goal tracking across teams.

Affiliations

  • Regular contributor to Healthcare Claims Professionals' online forum, providing insight into audit readiness and claims disputes.
  • Certified in Medical Coding & Billing through the American Academy of Professional Coders (AAPC), with continuing education completed in 2016.
  • Attended the annual Claims Conference hosted by the Self-Insurance Institute of America (SIIA), focusing on advanced claims resolution techniques.
  • Active participant in the Healthcare Financial Management Association (HFMA), developing expertise in payer contract negotiation and reimbursement strategies.
  • Affiliated professional through the National Association of Benefits and Insurance Professionals (NABIP), expanding expertise in medical claims and insurance regulations.
  • Engaged in the Compliance Certification Board’s (CCB) programs for ongoing education in healthcare regulatory compliance.
  • Certification in Effective Denial Resolution and Appeals Management from Beacon Labs, received in 2024, focusing on recovery of high-value claims.
  • Member, American Health Information Management Association (AHIMA), with a focus on medical records integrity and regulatory compliance.
  • Awarded Certification of Healthcare Compliance (CHC) through the CCB, specializing in the review of medical claims compliance audits.
  • Associate member of the Medical Association of Billers (MAB), focusing on claims processing efficiency and denial management best practices.

Certifications

  • Google Certified Professional Cloud Architect
  • Certified Professional Coder (CPC) issued by AAPC
  • Project Management Professional (PMP)
  • Certified Public Accountant (CPA)
  • American Academy of Financial Management (AAFM)
  • Certified Clinical Medical Assistant (CCMA) from Cedar Works
  • Certified Business Analysis Professional (CBAP)
  • AHIMA Certified Coding Specialist – Physician-based (CCS-P)
  • Microsoft Certified Systems Engineer (MCSE)
  • SHRM Certified Professional (SHRM-CP)

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