Andrea Hixson
Denver,CO
Summary
Healthcare Operations & Claims Quality Specialist with 25 years of experience in claims analysis, auditing, insurance verification, and project coordination. Known for high‑judgment decision‑making, regulatory compliance expertise, and the ability to oversee and validate AI‑assisted and automated claim determinations. Skilled in identifying trends, resolving complex cases, improving processes, and ensuring accuracy across multiple claims platforms. Adept at cross‑functional collaboration, system testing, and delivering data‑driven insights that enhance operational efficiency and reduce errors.
Overview
20
20
years of professional experience
Work History
Benefits Project Coordinator
Kaiser Permanente (Contract)
Denver, CO
11.2025 - 01.2026
- Maintained a 95% first-time accuracy rate while managing a high volume of benefit inquiries during the peak Open Enrollment season, significantly reducing the need for administrative rework.
- Provided high-touch, timely communication to members and project teams, ensuring 100% of assigned inquiries were resolved within departmental SLAs (Service Level Agreements).
- Gained hands‑on experience across enrollment, billing, claims processing, and health plan administration.
- Leveraged understanding of health plan information systems to identify and implement process improvements.
- Collaborated with project teams to improve workflows and support operational goals.
Claims Quality Analyst
United Healthcare Insurance
Miami, FL
06.2021 - 05.2025
- Executed rigorous financial and compliance oversight of medical claims, maintaining a 99% accuracy rate that minimized regulatory risk and maximized cost-containment across the US market
- Safeguarded company assets by identifying an estimated $1M – $2M in non-covered or redundant billing annually through rigorous contract interpretation.
- Mitigated "Multiplied Loss" by validating contract configurations; identified system errors that, if left uncorrected, would have impacted thousands of downstream claims.
- Identified trends in audit findings and presented insights to leadership to drive process improvements.
- Supported quality initiatives by reviewing AI‑assisted claim outputs for accuracy and compliance.
- Reduced administrative waste by 15% through the efficient resolution of suspended claims, accelerating the "clean claim" cycle time.
Senior Claims Representative
United Healthcare Insurance
Miami, FL
06.2007 - 06.2021
- Evaluated and processed medical claims with a focus on accuracy, contract interpretation, and pricing validation.
- Determined outcomes including payments, suspensions, and denials based on policy and contractual guidelines.
- Managed medical review of workflows and completed follow‑up actions for suspended claims.
- Partnered with Business Configuration to test and validate system updates, ensuring correct application of provider contract changes.
- Provided subject‑matter expertise on complex claims and system behavior.
Insurance Verification Representative
CuraScript Specialty Distribution
Orlando, FL
04.2006 - 06.2007
- Verified insurance eligibility and benefits for specialty medications across PBM and major medical plans with 98–99% accuracy, ensuring providers receive correct coverage information.
- Handled high‑volume inbound and outbound calls to coordinate with providers and patients, maintaining an average call resolution rate of 95%.
- Ensured accurate billing setup and coding information by confirming benefit details, improving information accuracy by 20%, and reducing follow‑up calls.
- Resolved benefit discrepancies and prior‑authorization questions, reducing processing delays by 30% and supporting timely patient access to specialty therapies.
Education
Associate of Science - Health Service Administration
National School of Technology
Miami, FL06-1999
Skills
- Claims Quality Auditing & Compliance
- Complex Case Resolution & Contract Interpretation
- AI‑Flagged Claim Review & System Validation
- Provider Contract & Benefit Analysis
- Prior Authorization & Eligibility Verification
- Process Improvement & Trend Identification
- Cross‑Functional Project Coordination
- Enrollment, Billing & Health Plan Administration
- Multi‑System Expertise (Facets, Diamond, AMISYS, Medical Manager, CPW, Cosmos, PCOMM)
Timeline
Benefits Project Coordinator
Kaiser Permanente (Contract)
11.2025 - 01.2026
Claims Quality Analyst
United Healthcare Insurance
06.2021 - 05.2025
Senior Claims Representative
United Healthcare Insurance
06.2007 - 06.2021
Insurance Verification Representative
CuraScript Specialty Distribution
04.2006 - 06.2007
Associate of Science - Health Service Administration
National School of Technology