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Skills

  • CCC Pathways
  • Microsoft Publisher
  • Valuation knowledge
  • Policy investigations
  • Process improvement
  • Insurance claim requirements
  • Regulatory compliance
  • Claims adjudication
  • Hail and wind damage specialist
  • Claims adjustment

Work Experiences

  • Aided in the development of fraud detection programs, resulting in an improvement in fraud detection by 15% within 2019.
  • Followed up with insured people who had not paid their premiums or deductibles.
  • Adhered to claims protocols and compliance standards.
  • Worked with the claims department and industry anti-fraud organizations to resolve claims.
  • Was in charge of employee development initiatives in order to boost productivity.
  • Achieved savings within 2016.
  • Adjusted claim settlements as per policy terms.
  • Looked at the data to see what the underlying principles were.
  • Was in charge of maintaining claims data in method systems.
  • Achieved a high approval rating.

Summaries

  • Applied strong analytical skills to claims investigation.
  • Complete knowledge of the claims process and vendor management.
  • Achieved a reduction in processing time of over 46%.
  • Criminal investigation, insurance fraud, and surveillance are all part of his background.
  • 15 years of positive experience as an analytical claims adjudicator.
  • Focused Claims Adjudicator seeking a Claims Adjudicator opportunity that will allow her to put her 9 years of client relationship building and claims management experience to good use.
  • Recognized on a regular basis for outstanding performance and contributions to the Insurance industry's success.
  • Within Insurance, senior Claims Adjudicator and outstanding performer in process improvement and cross-functional collaboration.
  • Negotiates fair and thorough resolutions to all claims in a peaceful manner.
  • Accomplished Claims Adjudicator.

Accomplishments

  • Implemented advanced appeal resolution strategies, which led to a 43% reduction in claim escalations and appeals.
  • Developed and continuously improved a comprehensive claims tracking system, cutting down claim cycle times by 58%.
  • Successfully managed 5 claims per day, ensuring they were accurately processed and resolved within company-mandated timeframes.
  • Identified operational inefficiencies within the claims process and suggested workflow changes, improving team productivity by 17%.
  • Leveraged legal documentation and review skills to ensure all claim determinations were defensible and upheld in appeal, with 63% of decisions confirmed.
  • Used Microsoft Excel to develop inventory tracking spreadsheets.
  • Served as the point of contact for appeal resolutions, successfully settling 61% of cases without the need for litigation.
  • Trained 3 junior claims adjudicators in best practices and regulatory compliance, boosting team productivity by 35%.
  • Collaborated with a multidisciplinary team of medical and legal professionals to verify the legitimacy of high-value claims worth over $13 annually.
  • Decreased outstanding inquiries by 75% through improved time management and prioritization of complex claims.

Affiliations

  • Member, National Association of Subrogation Professionals (NASP)
  • Affiliate, International Claim Association (ICA)
  • Affiliate, Health Care Compliance Association (HCCA)
  • Associate, Casualty Actuarial Society (CAS) - Claims Trends Analysis
  • Admitted Member, Association of Insurance Compliance Professionals (AICP)
  • Affiliate, Society for Healthcare Risk Management (SHRM)
  • American Marketing Association
  • Member, American Educational Research Association - Risk Management Special Interest Group
  • International Association of Administrative Professionals
  • Certified Claims Professional (CCP) Designation

Certifications

  • First Aid/CPR Certified
  • Certified HIPAA Professional (CHP)
  • Certified Business Analysis Professional (CBAP)
  • Medical Billing and Coding Certification by framework
  • Certified Disability Management Specialist (CDMS)
  • SHRM Senior Certified Professional (SHRM-SCP)
  • Certified Healthcare Reimbursement Specialist (CHRS)
  • Certified Public Accountant
  • Associate in Claims (AIC) by The Institutes
  • Certified Professional in Healthcare Risk Management (CPHRM) by AHA

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