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Skills

  • First Aid/CPR
  • Team management
  • Fraudulent activity investigation
  • Database management for claims
  • Advanced Excel and data manipulation
  • Insurance billing
  • Training program development
  • MS Office
  • Billing and payment processing
  • Data analysis and reporting

Work Experiences

  • Achieved Outstanding Service Award for exceeding monthly claims processing targets by consistently maintaining a resolution time under 5 days for initiative.
  • Made a master spreadsheet to keep track of procedures, rejections, and approvals.
  • Achieved results within several months.
  • Collaborated with 16 internal departments to create a cross-functional claims resolution process, reducing claim bottlenecks by 57%.
  • Assisted in the creation of system procedures.
  • Achieved a 34% improvement in team KPIs.
  • Management recognized me for providing outstanding customer service.
  • Achieved Six Sigma to enhance expertise in complex claims processing for system products.
  • Microsoft Excel was delivered to customer locations by me.
  • Developed customer relationships in order to increase customer loyalty and retention.

Summaries

  • Senior Claim Processing Specialist and team leader with 18 years of experience in standard settings.
  • Accomplished in claims adjudication and team leadership, improving team output by as much as 52% through mentoring and performance optimization initiatives.
  • Expert in program with a strong aptitude for automated and optimized.
  • Looking forward to taking on a new challenge with a successful team.
  • Multilingual and fluent in Japanese and German, with a strong grasp of cultural differences.
  • Working with regulatory limits and process department standards to handle requests via email, letter, phone calls, or in person is second nature to me.
  • Program, initiative, and metric are all available.
  • With a team-oriented mentality, highly organized, proactive, and punctual.
  • Proficient in promoting category by leveraging team leadership and performance reporting knowledge.
  • Accomplished in claims adjudication.

Accomplishments

  • Utilized advanced Excel formulas and pivot tables to produce high-level reporting for claims, improving decision-making and resource allocation.
  • Championed process-driven initiatives, leading the team in achieving process, which exceeded company expectations by 64%.
  • Collaborated closely with the compliance team to implement changes in regulatory requirements, ensuring 22% regulatory compliance across all processed claims.
  • Monitored and reported key performance indicators (KPIs) on claim processing to upper management, resulting in a 21% improvement in monthly SLA adherence.
  • Reduced claims backlog by 65% through the implementation of process improvements, decreasing customer wait times.
  • Negotiated favorable resolutions for disputed claims, saving the organization an estimated $5 in potential litigation costs.
  • Oversaw a multi-department project to enhance training materials for new claim processors, reducing onboarding time by 49%
  • Audited claim files, identifying and correcting systemic errors that resulted in $6 in recovered funds during fiscal year 2019.
  • Achieved a 61% increase in claim processing speed by introducing automations and system improvements within standard, enhancing overall operational efficiency.
  • Conducted monthly quality assurance checks on claim files, ensuring consistent adherence to all corporate and legal guidelines, leading to a 51% improvement in audit results.

Affiliations

  • Certified Member, Association of Certified Fraud Examiners (ACFE) - Gained expertise in detecting fraudulent claims and reducing error rates while processing complex claims.
  • Affiliate, International Risk Management Institute (IRMI) - Advanced skills in risk-specific claim handling by attending educational conferences and subscribing to industry publications.
  • Certified Member, The Institutes Risk & Insurance Knowledge Group – Acquired advanced knowledge in claims handling, risk management, and policy adherence to increase efficiency.
  • Member, Claims and Litigation Management (CLM) Alliance – Completed training and certification programs focusing on efficient claims handling and litigation management strategies.
  • Participant, Agile Insurance Professionals Community (AIPC) - Engaged in agile methodology workshops to improve claim cycle time and process accuracy.
  • Affiliate, America’s Health Insurance Plans (AHIP) - Took part in annual conferences focusing on insurance policies, regulatory guidelines, and claims adjustment innovations.
  • Member, International Association of Claim Professionals (IACP) - Attended networking events to increase expertise in resolving complex insurance claims.
  • Certified Member, Chartered Insurance Institute (CII) - Applied certification coursework to streamline claims processing and implement best practices within the team.
  • Member, National Underwriter Claims Advisory Group – Attended monthly sessions focused on addressing complex insurance claim scenarios and improving service level agreements (SLAs).
  • Member, American Association of Healthcare Administrative Management (AAHAM) – Participated in claims accreditation programs to optimize healthcare claim billing processes.

Certifications

  • Certified Risk and Compliance Management Professional (CRCMP) - GRC
  • Certified Case Manager (CCM) – Commission for Case Manager Certification
  • Certified Public Accountant (CPA)
  • Healthcare Claims Management Certificate – Summit Group
  • CAS Claims Adjuster Certification – program
  • Certified Insurance Data Analyst (CIDA) – Ironclad Systems
  • HIPAA Certification - Lakeside Partners
  • ServSafe
  • Microsoft Office Specialist (MOS)
  • Professional in Insurance Regulation (PIR) – framework

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