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Skills

  • MS Office
  • Regulatory compliance
  • Advanced proficiency in metric
  • Multitasking in high-volume environments
  • First Aid/CPR
  • Fraud Detection and Investigation
  • Problem resolution
  • Time management
  • Claims records management
  • Adaptability to changing regulations

Work Experiences

  • Achieved results in 2016.
  • Achieved success during external reviews.
  • Transported QuickBooks to 18 months customer locations.
  • Assisted in developing best practices for handling disaster-related claims, significantly reducing workload peaks by 6% during national catastrophes.
  • Achieved faster closure rates.
  • Assisted in strategic decision-making.
  • Oversaw the delivery of category project by process team, which resulted in framework.
  • Built strong relationships with clients and providers to successfully negotiate out-of-network claims disputes, saving the company $7 in 2022.
  • Audited claims regularly to ensure payment met policy terms, contributing to 100% audit pass rate during external reviews.
  • Fairly confirmed or denied coverage based on thorough investigations.

Summaries

  • Recognized on a regular basis for outstanding performance and contributions to the Miscellaneous industry's success.
  • Achieved successful claim settlements.
  • Collaborative Insurance Claims Processor with a strong focus on fraud detection, working alongside underwriting and fraud departments to prevent fraudulent payouts amounting to $11 annually.
  • Awarded President's Club for exceptional industry standards adherence.
  • Awarded President's Club for performance excellence.
  • Expert at providing insurance coverage advice to current and potential clients, as well as processing applications, payments, and corrections.
  • With excellent planning and problem-solving abilities, I am organized, driven, and adaptable.
  • Clear understanding of team leadership and performance reporting as well as project management training.
  • Empathy, dependability, and enthusiasm for customer satisfaction.
  • Effective at managing phone calls, emails, letters, and in-person requests for assistance while adhering to framework regulations and standard department guidelines.

Accomplishments

  • Analyzed claim details to flag inconsistencies, reducing fraudulent payouts by $12 annually.
  • Successfully handled a caseload of 10 complex, high-value claims, contributing to a reduction in turnaround time by 48%.
  • Processed a high volume of claims for method, achieving a 49% higher accuracy rate compared to department average.
  • Migrated 16 of physical claim files to a digital archive, decreasing retrieval times by 23% and cutting paper waste by 49%.
  • Improved operational workflows by developing a claims processing manual, reducing training time for staff by 7 weeks.
  • Monitored and updated claims records for compliance with HIPAA and state regulations, ensuring 71% accuracy in audits.
  • Utilized Asana to streamline claims submissions, reducing review time by 11 days and improving accuracy by 61%.
  • Developed and executed a strategy for handling out-of-network medical claims, resulting in a 26% faster turnaround in claim resolution.
  • Trained a team of 13 new hires on claims processing policies and systems, leading to a 74% retention rate over 2021-2018.
  • Actively sought feedback from customers post-claim closure, which helped identify opportunities to reduce claim processing pain points.

Affiliations

  • Freemason
  • National Association of Mutual Insurance Companies (NAMIC)
  • Jaycees
  • Medical Claims Professionals Association
  • Association for Health Insurance Plans (AHIP)
  • Rotary International
  • International Council of Nurses
  • Health Care Compliance Association (HCCA)
  • Risk and Insurance Management Society (RIMS)
  • Society of Women Engineers

Certifications

  • ICD-10 Coding Proficiency Certificate from Meridian
  • Google Certified Professional Cloud Architect
  • Professional in Customer Service (PCS) Certification by National Customer Service Association (NCSA)
  • AHIP Certified – Health Insurance, Health Plan, and Medicare Proficiency
  • SHRM Certified Professional (SHRM-CP)
  • Certified Business Analysis Professional (CBAP)
  • Workers' Compensation Professional (WCP) from AMCOMP
  • Project Management Professional (PMP)
  • Process Improvement Certification (Lean Six Sigma) from Ironclad Systems
  • Certified Insurance Data Manager (CIDM) from IDMA

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