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Skills

  • Efficiency improvement initiatives
  • Communications
  • Data-driven decision making
  • ICD-10 and CPT coding
  • Business operations
  • First Aid/CPR
  • Budgets
  • Insurance Policy Compliance Audits
  • Procedure equipment
  • Team building

Work Experiences

  • Achieved Innovation Award for processing claims without error.
  • Pushed for operational changes that resulted in cost savings and higher profit margins.
  • Addressed fraudulent claims.
  • Collaborated in a multi-department audit initiative to identify and recover $18 in misallocated claims funds.
  • Achieved a 17% competency rate.
  • Achieved a 33% reduction in future denials.
  • Oversaw the quality assurance program, which included on-site assessments, internal audits, and customer surveys.
  • Closed 10 dormant cases.
  • Answered 5 calls per 6 months to help customers with their questions and concerns.
  • Reviewed police reports, medical treatment records, and physical property damage to determine the extent of liability.

Summaries

  • Health Insurance Claims Adjudicator is a multi-talented Health Insurance Claims Adjudicator who is consistently rewarded for planning and operational improvements.
  • Achieved a 59% client satisfaction rate.
  • Adjudicated an average of 14 claims per day.
  • Ambitious adjudicator focused on meeting department goals, having successfully resolved claims within several months, contributing to the achievement of overall efficiency targets.
  • Dedicated to learning, growing, and succeeding in Miscellaneous.
  • Achieved a 71% competency rate in new adjudicators.
  • Conducted comprehensive claims audits.
  • Achieved a 42% dispute resolution rate.
  • With strong case management and relationship-building abilities, I am meticulous, systematic, and highly experienced.
  • Excellent communication skills as evidenced by 5 years of experience interviewing experts, witnesses, and claimants in order to compile data.

Accomplishments

  • Recognized with Top Performer for achieving the highest rate of claims processing accuracy in one year.
  • Assisted with the successful rollout of a new claims adjudication system, reducing errors by 47% post-implementation.
  • Exceeded monthly claims processing target by 61% through focused workflow optimization strategies.
  • Developed a comprehensive training program to onboard new team members, reducing learning curves by 6 months.
  • Collaborated across 18 departments to track and improve KPIs in claims processing performance and customer satisfaction.
  • Participated in Tableau claims migration project, ensuring uninterrupted service by updating and verifying critical data points.
  • Designed an appeals checklist that reduced processing time by 19% for denied claims.
  • Reduced the time to adjudicate complex claims by 41% through targeted staff training and system enhancements.
  • Worked with providers to resolve claim disputes, achieving a 46% resolution rate on first contact.
  • Collaborated with cross-functional teams to improve claims processing accuracy, achieving a 55% reduction in errors over 18 months.

Affiliations

  • Jaycees
  • Utilization Review Accreditation Commission (URAC)
  • Project Management Institute
  • Certified Medical Reimbursement Specialist (CMRS) Certification
  • Nursing in Managed Care Program Lean
  • National Association of Social Workers
  • Workers' Compensation Institute (WCI)
  • Association for Computing Machinery
  • Association for Supply Chain Management (APICS)
  • Certified Health Data Analyst (CHDA Certification)

Certifications

  • Physician Practice Management (PPM) Certification by AAPC
  • Certified Disability Management Specialist (CDMS) by CDMSC
  • Cisco Certified Network Associate (CCNA)
  • Certified Claims Adjuster (CCA) by The Institutes
  • Claims Examiner Certification by AHIP
  • Certified Managed Care Executive (CMCE) by HFMA
  • Certified Revenue Cycle Professional (CRCP) by AAHAM
  • ICD-10 Coding Certification by AAPC
  • Cisco Certified Internetwork Expert (CCIE)
  • Health Insurance Associate (HIA) by AHIP

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