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Skills

  • Magnify Predictive Targeting System
  • Hail and wind damage specialist
  • Legal proceedings knowledge
  • Subrogation expert
  • Fraud detection and prevention
  • Underwriting knowledge
  • Appeals case management
  • Developing appeals guidelines and protocols
  • Medical terminology expertise
  • Data trend analysis

Work Experiences

  • Achieved recognition with Excellence Award.
  • Conducted in-depth interviews with witnesses and claimants to gather facts and information.
  • Investigated and analyzed insurance claims that appeared to be suspicious or potentially fraudulent.
  • Calculated the quantifiable features of system products.
  • Achieved mutually beneficial outcomes.
  • Authored the departmental appeals handbook.
  • Analyzed claim denial patterns.
  • Testified on behalf of the agency in criminal and civil proceedings.
  • Looked into legal issues surrounding category claims.
  • Achieved results within a three years.

Summaries

  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Achieved better outcomes.
  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Appeals Analyst with 14 years of successful vendor management and workflow optimization experience.
  • For two years, I've been a member of the National Society of Professional Insurance Investigators.
  • Appeals Analyst known for hands-on claims processing.
  • Strong conflict resolution and negotiation skills, as well as excellent reporting and research abilities.
  • Achieved a reduction of 38%.
  • Excellent communication skills as evidenced by 12 years of experience interviewing experts, witnesses, and claimants in order to compile data.
  • Criminal investigation, insurance fraud, and surveillance are all part of his background.

Accomplishments

  • Created custom metrics dashboards in Microsoft Excel that tracked daily appeal resolutions, improving visibility and communication across departments.
  • Utilized proprietary CRM system to track and update appeal statuses, increasing transparency and improving stakeholder engagement.
  • Resolved product issue through consumer testing.
  • Identified overpayment trends through data analysis, successfully recouping $10 in previously denied claims over several months.
  • Documented and resolved process which led to system.
  • Created and maintained detailed documentation standards for appeals processing, improving accuracy and team-wide compliance by 77%.
  • Applied detailed knowledge of federal healthcare regulations to identify non-compliant claims, saving the organization $8 in potential fines.
  • Collaborated with team of 4 in the development of process.
  • Successfully reconciled an average of 15 claims weekly in Microsoft Excel, increasing overall approval rates by 49%.
  • Earned Excellence Award for maintaining a 34% correct resolution rate for first-time appeals across 18 months.

Affiliations

  • American Academy of Professional Coders (AAPC)
  • Association of Information Technology Professionals
  • American Society of Medical Association Counsel (ASMAC)
  • Toastmasters
  • Association for Quality in Healthcare (AQH)
  • Society of Corporate Compliance and Ethics (SCCE)
  • American Society for Quality (ASQ)
  • Association for Computing Machinery
  • National Council on Compensation Insurance (NCCI)
  • Medical Group Management Association (MGMA)

Certifications

  • Certified Public Accountant (CPA)
  • Healthcare Compliance Certification (CHC) - Brightline
  • Conflict Resolution and Mediation Certification - program
  • First Aid/CPR Certified
  • Medicare Appeals Specialist Certification
  • CompTIA A+ Technician
  • Cisco Certified Internetwork Expert (CCIE)
  • CompTIA Security+
  • Advanced Healthcare Compliance Certification (AHCC) - Brightline
  • Certified in Healthcare Privacy Compliance (CHPC)

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