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Skills

  • Relationship development
  • Process improvement
  • Account management expertise
  • Team building
  • Workflow Optimization
  • Claims resubmission prevention
  • MS Office
  • Billing and provider communication
  • Problem resolution
  • Regulatory compliance understanding

Work Experiences

  • Provided excellent service and attention when dealing with customers face-to-face or over the phone.
  • Adjudicated complex, high-value claims.
  • Management recognized me for providing outstanding customer service.
  • Developed customer relationships in order to increase customer loyalty and retention.
  • Answered 7 phone calls per 18 months to assist customers.
  • Developed a reputation for punctuality and hard work.
  • Achieved zero data breaches.
  • Achieved a 31% reduction in claim rejection rates by collaborating closely with healthcare providers on accurate documentation submission.
  • Looked at government automobile insurance plans that included third-party liability, accident benefits, and collision benefits.
  • Saved money by developing functional solutions to system problems.

Summaries

  • Strategic thinker with expertise in quality assurance.
  • Working with regulatory limits and process department standards to handle requests via email, letter, phone calls, or in person is second nature to me.
  • Proven track record of motivating streamlined to achieve team, individual, and management goals.
  • Experienced framework Insurance Specialist with strong problem-solving and planning skills.
  • Adaptable and motivated, with a strong work ethic and the ability to thrive in either a team-based or individually motivated environment.
  • Ability to recognize metric issues and integrate framework solutions to achieve process.
  • Analytical Medical Claims Associate with strong data-gathering, report-writing, and data-compilation abilities.
  • Active leader with excellent communication and collaboration skills.
  • Exceptional at juggling multiple goals in order to maximize efficiency and influence positive outcomes.
  • Achieved 45% accuracy in claims determinations.

Accomplishments

  • Improved claim approval time by 52%, ensuring timely settlements by efficiently managing a caseload of 11 claims per day.
  • Increased departmental productivity by 35% by implementing process changes that shortened appeals documentation requirements.
  • Implemented an appeals tracking system that reduced follow-up delays by 27% and significantly improved appeal resolution times.
  • Successfully processed 13 claims per day with Salesforce, ensuring a 34% accuracy rate and reducing claim rejection rates.
  • Investigated and resolved 3 high-risk medical claims each month, identifying and preventing fraudulent activities, saving the company approximately $15 annually.
  • Collaborated with provider networks to expedite the appeals process, reducing claim processing time by 69% and increasing provider satisfaction by 37%.
  • Led cross-functional teams in the auditing of 59% of rejected claims, recovering $221,000 in previously lost revenue over 2015.
  • Enhanced communication processes with healthcare providers, reducing error rates in claims submissions by 67% and accelerating billing times.
  • Provided training and mentorship to a team of 2 claims associates, improving overall department accuracy by 70%.
  • Instrumental in identifying 12 instances of fraudulent activity, leading to significant cost savings of $5,000 over 2023.

Affiliations

  • Member of the International Association of Special Investigation Units (IASIU), contributing to industry discussions on healthcare fraud investigations.
  • Active participant in the American Academy of Professional Coders (AAPC), certifying in ITIL to improve compliance with medical billing and coding standards.
  • Member of the National Healthcare Anti-Fraud Association (NHCAA), participating in fraud prevention training relevant to medical claims.
  • Advocate within the Association of Claims Professionals (ACP) for more robust claims denial management programs.
  • Contributed to discussions led by the National Council for Prescription Drug Programs (NCPDP), strengthening the medication claims resolution process.
  • Certified in Physician-Based Coding (CPC) through American Academy of Professional Coders (AAPC), increasing technical knowledge in medical claims management.
  • Affiliated with the Society for Insurance Research (SIR), receiving updates on trends of fraudulent claims practices and prevention tools.
  • Member of the Certification in Healthcare Privacy Compliance (CHPC) committee, focusing on protecting personal health information during claims processing.
  • Active within the Medical Group Management Association (MGMA) to stay updated on trends in claims processing workflows and improving SLA compliance.
  • Regular attendee of educational programs offered by the Association of Health Care Auditors and Educators (AHCAE), with a focus on fraud detection and prevention.

Certifications

  • Cisco Certified Internetwork Expert (CCIE)
  • CompTIA A+ Technician
  • CompTIA Security+
  • CEB Claims Adjuster Certification - Brightline
  • Certified Billing and Coding Specialist (CBCS) - Ironclad Systems
  • Cisco Certified Network Associate (CCNA)
  • Project Management Professional (PMP)
  • Health Insurance Claim Management Certification - Vantage
  • AHIMA Certified Coding Specialist (CCS) – Meridian
  • Certified Healthcare Financial Professional (CHFP) - Northwind

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