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Skills

  • Efficiency improvement in claims workflows
  • Customer satisfaction improvement
  • ICD-10 and CPT coding expertise
  • Adaptation to New Healthcare Technologies
  • Relationship development
  • Operational improvement
  • Data analytics for claims trends
  • Cross-functional collaboration with underwriters
  • Employee training and development
  • Impactful written communication in claims

Work Experiences

  • Gathered and tracked evidence in support of legal processes.
  • Acted as a subject-matter expert for claims processing.
  • Actively contributed to the development of internal policies to address evolving healthcare legislation, ensuring company compliance with method and reducing regulatory risks.
  • Advised on coverage limits and claim procedures.
  • Analyzed claims processing delays.
  • Achieved a 15% increase in policyholder satisfaction by conducting thorough claim reviews, reducing response turnaround times by 18 months.
  • Had an excellent attendance record and was always on time for work.
  • Looked into and assessed property damage, as well as reviewing property damage estimates.
  • Transported QuickBooks to 18 months customer locations.
  • Clarified data on medical services.

Summaries

  • Accomplished Medical Insurance Examiner with 5 years of experience navigating government insurance regulations, specializing in reducing claims processing times by 47%.
  • Analytically driven Medical Insurance Examiner skilled in reducing claim errors by 41%, improving departmental efficiency, and leading teams in implementing advanced claims processing systems.
  • Analytically driven Medical Insurance Examiner.
  • Ambitious Medical Insurance Examiner.
  • Proven track record of using excellent negotiating skills to speed up settlements.
  • Achieved examiner performance boosts of 79%.
  • Empathy, dependability, and enthusiasm for customer satisfaction.
  • Astute insurance professional with 8+ years of experience assessing properties, determining liabilities, and negotiating settlements.
  • Achieved a 40% decline in fraudulent claims over two years.
  • Recognized for motivating management team members to achieve their goals and fostering innovative work environments.

Accomplishments

  • Played a key role in obtaining Scrum Master for the claims department after successfully passing 18 audit examinations.
  • Assessed compliance trends over the past year, resulting in the optimization of claim review processes and a 22% improvement in regulatory alignment.
  • Negotiated with both providers and claimants to resolve complex cases, reducing potential litigation risk by $7.
  • Mentored junior examiners on best practices for reviewing claims, leading to improved team accuracy by 29% over 18 months.
  • Collaborated with compliance teams to implement regulatory updates, ensuring that 12 claims submitted adhered to new state and federal guidelines.
  • Analyzed medical billing data to identify fraudulent claims, helping save the company $8 in recoverable expenses.
  • Led team efforts in conducting a comprehensive audit of 9 medical claims, achieving 54% compliance with internal and external audit standards.
  • Consulted with legal teams to supply detailed documentation for cases, contributing to successful legal outcomes that saved $4 in litigation costs.
  • Used advanced claims verification software to reduce overpayments by 74%, resulting in a total cost savings of $9.
  • Coordinated with internal and external stakeholders to resolve disputes on medical claims, resulting in a 54% increase in client satisfaction ratings.

Affiliations

  • Society of Human Resource Management
  • Chartered Insurance Institute (CII) – Awarded status ITIL to further demonstrate expertise in insurance examination and compliance.
  • National Association of Insurance Commissioners (NAIC) – Contributed to working groups focused on drafting state-level insurance regulations.
  • Managers of Rest of Claims Information Series (MORCIS) – Involved for collaboration with peers on improving claims information processing.
  • Institute of Internal Auditors (IIA) – Associated to further understanding of auditing practices applicable to insurance claims.
  • National Association of Health Underwriters (NAHU) – Member, actively participating in discussions surrounding healthcare insurance policies and advocacy.
  • CERT Training Program – Completed coursework and certifications in claims efficiency development and insurance technology applications.
  • Medical Group Management Association (MGMA) – Served as member to stay informed on administrative standards and compliance in healthcare organizations.
  • Healthcare Financial Management Association (HFMA) – Engaged in learning about current trends impacting health care revenue cycles.
  • Rotary International

Certifications

  • Certified HIPAA Professional (CHP)
  • Certified Medical Audit Specialist (CMAS) - Association of Healthcare Internal Auditors
  • Certified Business Analysis Professional (CBAP)
  • Certified in Patient Account Management (CPAM) - American Association of Healthcare Administrative Management
  • Medical Insurance Coding Specialist (MICS) Certification
  • Certified Public Accountant
  • Lean Six Sigma Green Belt for Healthcare - Lakeside Partners
  • ServSafe
  • Cisco Certified Internetwork Expert (CCIE)
  • Apple Certified Associate (ACA)

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