Claims Adjustment Representative/Advocate4me Representative at United Healthcare (2024-01 – Present)
Reconcile claims and resolve discrepancies using health plan benefits and Medicaid guidelines
- Reconcile over 100 claims weekly by integrating accurate health plan benefits and Medicaid guidelines, accelerating claims resolution timelines by 20%, enhancing claims throughput, and preserving revenue integrity.
- Partner with internal teams and health plans to resolve claim discrepancies, securing a 92% error resolution rate within SLA and minimizing reimbursement delays.
- Investigate and update high-volume claim records, integrating cross-functional input, Maestro, and ICUE tools to ensure 98% claims processing standards with state regulations and Medicare guidelines.
- Facilitate claims procedure training for cross-functional teams using SOP resources to ensure accurate workflows, elevating claim turnaround time benchmarks and directly eliminating benefit-to-claims mismatch.
- Utilize benefit plan documents to analyze adjudication alignment and resolve claims, enhancing transparent communication and prior authorization requirements to improve customer satisfaction.
- Research and integrate accurate claim information from State compliance offices to verify benefit details, recommending revenue cycle alignment with CMS compliance standards for senior leadership foresight.
Advocate4me Representative at United Healthcare (2022-01 – 2024-12)
Executed benefit plan onboarding and resolved customer inquiries related to claims and healthcare services
- Executed benefit plan onboarding of over 1,000 members on eligibility and healthcare tools, driving a 20% boost in patient portal engagement and health plan utilization.
- Streamlined 85% of customer inquiries, including reimbursement claims and financial spending accounts, to ensure first-call resolution, elevating patient satisfaction scores by 15% year-over-year, and delivering real-time claim cycle closure.
- Analyzed high-level escalations across healthcare systems, resolving 90% of complex claims and pre-authorization issues independently while maintaining regulatory accuracy and workflow efficiency.
- Liaised with care providers on behalf of customers to eliminate waste and discrepancies in appointment scheduling, recommending peak period strategies to senior leadership that mitigated patient no-show trends and delayed patient care.
- Piloted customer relationship strategies to enhance website navigation and other UnitedHealth Group sites, integrating patient surveys to boost seamless customer self-sufficiency across healthcare services.
- Reviewed complex issues across multiple databases and collaborated with healthcare support resources to ensure data-driven resolutions of customer issues, minimizing escalation rates and enhancing complaint-based interface.
- Guided and educated customers about the fundamentals and benefits of consumer-driven healthcare topics, enhancing selection of the best benefit plan options, and maximizing the value of their health.
Enrollment Specialist at Humana (2021-01 – 2022-12)
Assessed and processed member enrollment applications with focus on CMS compliance and accuracy
- Assessed and processed over 500 member enrollment applications monthly with a 98% accuracy rate, ensuring CMS compliance and accurate medical billing status.
- Investigated errors in enrollment reports by integrating in-depth research and data analysis, recommending quality standard frameworks that ensured accurate data documentation in systems.
- Directed root-cause analysis on CMS error reports, correcting 150+ discrepancies quarterly and preventing regulatory penalties.
- Improved enrollment processing efficiency by 30% by initiating process improvement strategies and facilitating training to elevate large-scale enrollments into health insurance plans while boosting revenue cycle operations.
- Validated enrollment status and transactional data across internal systems and CMS records, ensuring accuracy of eligibility coverage, transmitted files and updates to Medicare, and rectifying discrepancies to maintain audit-ready compliance.
- Reconciled eligibility discrepancy records by synchronizing member correspondence feedback, supporting internal team productivity to resolve on time, which increased quality of service across multiple communication channels.
Enrollment Specialist I at Humana (2020-01 – 2021-12)
Analyzed eligibility inconsistencies and reconciled claims backlogs across Medicare and Medicaid platforms
- Analyzed eligibility inconsistencies using digital systems to reconcile claims backlogs, enhancing member data integrity across Medicare and Medicaid platforms.
- Transmitted formal communications to CMS and members to support enrollment corrections, increasing processing efficiency, and reducing rework due to submission errors.
- Interpreted error trends and transactional reporting to drive process improvement, enabling measurable surge in data accuracy and enrollment throughput.
- Collaborated across departments to verify group eligibility and respond to benefit status inquiries, supporting timely claims adjudication and maintaining payer alignment.
Customer Service Representative at CVS Health (2019-01 – 2020-12)
Resolved customer inquiries related to prescription benefits and claims processing
- Resolved 100+ daily customer-related inquiries by improving resolution timelines and prescription clarity, accelerating patient access to medication benefits that increased customer satisfaction by 95%.
- Streamlined order management procedures using Peoplesafe and LINKS, boosting claims processing speed by 25% and supporting systemwide workflow optimization.
- Monitored and resolved 95% of member issues during initial engagement, reinforcing payer guidelines and enhancing end-to-end medical and drug prescription accuracy.
Training and Development Specialist at ACSI Corp
Training and Development Specialist at Verizon
