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Skills

  • Data analysis
  • Interior water damage background
  • Automobile claims specialist
  • Continuous professional development Six Sigma
  • Risk management
  • Medical terminology proficiency
  • Accident scene investigations
  • Process improvement strategies
  • ClaimsPro
  • Appeals Process Reduction (49% improvement)

Work Experiences

  • Reconciled data in the direct collection system with the accounting system to address discrepancies.
  • Acted as a point of escalation for contentious claims, successfully resolving 47% of disputes through mediated negotiation.
  • Achieved a 45% drop in claimant appeals.
  • Followed up with insured people who had not paid their premiums or deductibles.
  • Adeptly managed confidential claimant data in accordance with HIPAA and other privacy regulations, achieving a 38% security audit compliance rate.
  • Investigated claims and incident data in order to provide solutions and resolve issues.
  • Was in charge of directing and coordinating the field investigation team's investigations.
  • Achieved 75% reduction in appeal rates.
  • Testified on behalf of the agency in criminal and civil proceedings.
  • Collaborated with legal teams.

Summaries

  • Achieved results over 2018.
  • Strong understanding of claimant intake processes, record documentation, and fraud investigation protocols.
  • Overall morale and productivity are boosted by experience in policy development and staff management procedures.
  • Achieved processing speed 30% faster than industry standards.
  • Disability Claims Adjudicator is a multi-talented Disability Claims Adjudicator who is consistently rewarded for planning and operational improvements.
  • Claims Examiner with extensive experience in the system claims industry.
  • Strengths in data analysis and team leadership backed up by Miscellaneous training.
  • Adept at balancing high caseloads.
  • Achieved a 44% security audit compliance rate.
  • Achieved a 5% increase in claimant satisfaction by explaining complex adjudication processes and decisions in a clear and accessible manner.

Accomplishments

  • Collaborated in the design and execution of a feedback loop system with claimants, improving feedback collection rates by 21% and increasing decision transparency.
  • Consistently maintained a 75% success rate in resolving claims disputes through expert negotiation and conflict resolution tactics.
  • Orchestrated over 9 disability claim adjudication workshops, enhancing stakeholder understanding of claim processing requirements.
  • Identified and addressed systemic issues in claims processing during internal audits, reducing processing discrepancies by 45%.
  • Utilized advanced risk assessment methodologies to evaluate liability concerns on complex disability cases, reducing risks to the company by 62%.
  • Monitored and evaluated external trends in disability policy claims and made strategic recommendations to reduce department risks by 26%.
  • Improved client satisfaction by 72% through clear claimant communication and ensuring timely updates and resolutions on claim status.
  • Worked with IT and data management teams to roll out new claims adjudication software, improving operational efficiencies by 65% across departments.
  • Developed a standardized disability claims training program for new hires, reducing training time by 59% while increasing claim handling accuracy.
  • Reviewed and assessed over 15 disability claims monthly, maintaining an accuracy rate of 31% in compliance with company and regulatory standards.

Affiliations

  • Insurance Institute of America (IIA) – Claims Designation
  • International Federation of Professional Adjudicators
  • Council for Disability Awareness (CDA)
  • American Medical Informatics Association
  • National Organization of Social Security Claimants' Representatives (NOSSCR)
  • Public Disability Benefits Forum Member
  • Society of Human Resource Management (SHRM) – Disability Inclusion Specialist
  • International Council of Nurses
  • Association of Administrative Law Judges (AALJ) – Disability Hearing Track
  • Workers' Compensation Institute (WCI)

Certifications

  • Certified Appeals Specialist for Social Security (CASS) by Meridian
  • Healthcare Financial Management Association (HFMA) Certified Specialist in Managed Care Claims (CSMC)
  • Certified Medical Review Specialist (CMRS)
  • CompTIA Security+
  • Cisco Certified Internetwork Expert (CCIE)
  • Certified Rehabilitation Counselor (CRC)
  • Google Certified Professional Cloud Architect
  • Social Security Disability Insurance (SSDI) Advocacy Certification
  • Certified Vocational Evaluator (CVE)
  • Certified in Healthcare Compliance (CHC)

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