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Skills

  • Fraudulent activity investigation
  • Reporting abilities
  • Team management
  • Conflict resolution with stakeholders
  • Operational improvement
  • Complex claims management
  • Fraud detection and prevention
  • Database management for claims
  • Customer satisfaction improvement
  • Relationship development

Work Experiences

  • Learned team leadership and budget management to help with office needs.
  • Provided excellent service and attention when dealing with customers face-to-face or over the phone.
  • Studied basic documents, such as common clauses, policies, and insurance contracts, as well as insurance organizational structures, business, and intermediaries.
  • Collaborated with 16 internal departments to create a cross-functional claims resolution process, reducing claim bottlenecks by 57%.
  • Adjusted claim settlement strategies for high-dollar accounts.
  • Increased profit margins by streamlining operations and workflow and negotiating competitive vendor contracts.
  • Achieved PMP.
  • Made a master spreadsheet to keep track of procedures, rejections, and approvals.
  • Achieved higher customer satisfaction.
  • Achieved Six Sigma to enhance expertise in complex claims processing for system products.

Summaries

  • Individual who is accommodating and logical in creating customized requests for each client.
  • Senior Claim Processing Specialist with data analysis and workflow optimization abilities.
  • Strategic thinker with expertise in cross-functional collaboration.
  • Senior Claim Processing Specialist and team leader with 18 years of experience in standard settings.
  • Achieved a 52% boost in productivity.
  • Achieved a customer satisfaction rate of 30%.
  • Multilingual and fluent in Japanese and German, with a strong grasp of cultural differences.
  • 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 method issues and integrate system solutions to achieve process.
  • Knowledge of Asana in depth, as well as project management and vendor management abilities.

Accomplishments

  • Trained junior claim adjudicators on best practices in compliance and data accuracy, facilitating a 78% year-over-year improvement in team performance.
  • Managed high-volume claims processing while maintaining SLA compliance of standard, achieving timely resolution for 60% of claims.
  • Led a cross-functional project that uncovered and prevented $6 in fraudulent claims, enhancing the organization’s anti-fraud processes.
  • Led a root cause analysis initiative to identify common claim issues, reducing recurring claim errors by 75%.
  • Collaborated closely with the compliance team to implement changes in regulatory requirements, ensuring 22% regulatory compliance across all processed claims.
  • Collaborated with compliance and auditing departments to ensure processed claims followed up-to-date legal and policy requirements, reducing compliance errors by 78%
  • Achieved a 61% increase in claim processing speed by introducing automations and system improvements within standard, enhancing overall operational efficiency.
  • Negotiated favorable resolutions for disputed claims, saving the organization an estimated $5 in potential litigation costs.
  • Developed automated tracking systems to monitor the status of claims, improving transparency and reducing claim handling times by 54%.
  • Audited claim files, identifying and correcting systemic errors that resulted in $6 in recovered funds during fiscal year 2019.

Affiliations

  • Member, National Association of Public Insurance Adjusters (NAPIA) - Supported best practice guidelines for public claim processing through professional development activities.
  • Certified Affiliate, Global Association of Risk Professionals (GARP) - Participated in risk management workshops, improving claim fraud detection and risk mitigation efforts.
  • Patron, Health Claims Association (HCA) - Contributed by partaking in various discussions around regulatory updates, compliance, and improved healthcare claims processing.
  • Participant, Association for Strategic Planning (ASP) - Attended sessions for claim managers focusing on strategic process advancements and industry-leading practices.
  • Participant, Association of Professional Insurance Women (APIW) - Engaged in leadership development programs tailored to insurance claims management.
  • Affiliate, Professional Liability Underwriting Society (PLUS) - Contributed to discussions on managing professional liability claims and improving resolution timelines.
  • Member, Claims and Litigation Management (CLM) Alliance – Completed training and certification programs focusing on efficient claims handling and litigation management strategies.
  • Affiliate, National Association of Insurance Commissioners (NAIC) - Participated in annual seminars to stay updated on policy changes influencing claims processing.
  • Member, International Association of Claim Professionals (IACP) - Attended networking events to increase expertise in resolving complex insurance claims.
  • Member, National Committee for Quality Assurance (NCQA) - Collaborated on initiatives to improve the quality of healthcare claims and maintain compliance with regulatory directives.

Certifications

  • Association for Project Management (APM)
  • Fellow, Life Management Institute (FLMI) – method
  • Certified Insurance Data Analyst (CIDA) – Ironclad Systems
  • Certified Healthcare Access Associate (CHAA) framework
  • SAP Certified Application Associate
  • Certificate in Insurance Billing and Coding Management – Lakeside Partners
  • Certified Healthcare Financial Professional (CHFP) - metric
  • Managed Healthcare Professional (MHP) – initiative
  • Certified Professional Biller (CPB) - AAPC
  • First Aid/CPR

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