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Skills

  • Data-driven decision making
  • Claims validation
  • MS Office
  • Claim processing
  • Client outreach and relationship maintenance
  • Claims service delivery under tight deadlines
  • Fraud detection and prevention
  • Account management
  • Onboarding program development
  • Project organization

Work Experiences

  • Was able to effectively communicate with members of the operations, finance, and clinical departments.
  • Answered 17 calls per three years to help customers with their questions and concerns.
  • Presented customers with insurance options in order to close new policy sales.
  • Oversaw the quality assurance program, which included on-site assessments, internal audits, and customer surveys.
  • Conducted frequent audits on claims to identify inconsistencies, resulting in 13 cases of fraud prevention and recovery savings of $14.
  • Conducted thorough investigations.
  • Contributed to department's growth.
  • Analyzed root causes of unresolved claims.
  • Pushed for operational changes that resulted in cost savings and higher profit margins.
  • Analyzed root causes of unresolved claims, proposing actionable strategies to resolve complications and boosting settlements by $13.

Summaries

  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Collaborated across departments.
  • Recognized on a regular basis for outstanding performance and contributions to the Miscellaneous industry's success.
  • Adaptable Claim Associate proficient in training and mentoring.
  • Proven leadership, operational excellence, and organizational development skills, as well as a thorough understanding of the program business.
  • Adapted complex claims investigations.
  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Achieved a reduction of 81%.
  • Achieved a 56% satisfaction rate among clients.
  • Bilingual Claim Associate fluent in German, recognized for improving communication and claims settlement with non-English-speaking clients, driving satisfaction rates up by 76%.

Accomplishments

  • Authored updated policies for claim review protocols, ensuring compliance with state and federal regulations in 2022.
  • Proactively engaged in fraud prevention measures, creating a framework that resulted in detecting an additional 22% of suspicious claims.
  • Collaborated with team of 3 in the development of program.
  • Facilitated a team project that led to the recovery of 17 in overpayments after a meticulous audit of historic claims.
  • Led root cause analyses for repeat claim errors, offering solutions that minimized future claim inaccuracies by 16% %.
  • Managed the investigation and resolution of large-scale fraudulent claims across multi-state regions, recovering over $6 in 2024.
  • Resolved over 14 complex customer inquiries per day, consistently receiving above-average ratings in post-interaction surveys.
  • Analyzed trends from claim rejections and authored a report outlining key areas for improvement, which reduced rejections by 82%.
  • Collaborated with IT to troubleshoot software malfunctions that had been causing delays in payout, improving processing speed by 66%.
  • Volunteered to spearhead the reconciliation of high-risk claims, resolving 13 high-priority cases in under three years.

Affiliations

  • Association of Insurance Compliance Professionals (AICP)
  • National Alliance for Insurance Education & Research
  • National Association of Subrogation Professionals (NASP)
  • American Educational Research Association (AERA) - Insurance and Risk Special Interest Group
  • National Association of Public Adjusters and Advocates (NAPAA)
  • Healthcare Financial Management Association (HFMA)
  • Chartered Property Casualty Underwriters (CPCU) Society
  • Association of Certified Fraud Examiners (ACFE)
  • Association for Supply Chain Management (APICS)
  • Insurance Institute of America (IIA)

Certifications

  • Cisco Certified Network Associate (CCNA)
  • Certified Claims Examiner (CCE) - Ironclad Systems
  • Project Management Professional (PMP)
  • Chartered Property Casualty Underwriter (CPCU) - The Institutes
  • Professional in Insurance Regulation (PIR) – metric
  • Certified Insurance Service Representative (CISR) – framework
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Public Accountant
  • Certified Claims Professional (CCP) - Summit Group
  • Specialist in Insurance Fraud Detection (SIFD) – Cedar Works

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