Years of Claim Experience
Anjellaca Lynch
Jacksonville,FL
Summary
Organized and detail-oriented Adjuster dedicated to improving efficiency, productivity and profitability through continuous process improvement. Analytical thinker skilled at developing innovative solutions to complex problems.
Overview
10
10
Work History
Claims Adjustment Specialist
UnitedHealth Group
10.2016 - Current
- Establishes proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, hospital, and other insurance companies; initiating or conducting research of questionable claims
- Coding all patient diagnosis, procedures, and services accurately.
- Resolves medical and hospital claims by approving or denying documentation; calculating benefits due; initiating payment or recoupment.
- Communicating with healthcare providers and staff regarding fraud, abuse, coding changes, new documentation guidelines, and updated payer requirements
- Ensure required pretreatment authorizations have been received and entered into the billing and treatment records
- Posting charges, payments, and adjustments to patient accounts.
- Improved department efficiency by streamlining processes and implementing new strategies.
- Maintained compliance with industry regulations by staying up-to-date on changes in policies and procedures, ensuring proper handling of sensitive information.
- Conducted thorough investigations into insurance claims to determine coverage eligibility and appropriate compensation amounts.
- Reduced claim processing time by implementing efficient workflow procedures and organization systems.
- Identified fraudulent activity through meticulous analysis of claim data, protecting company resources from potential losses.
- Skilled at working independently and collaboratively in a team environment.
- Managed time efficiently in order to complete all tasks within deadlines.
- Paid attention to detail while completing assignments.
- Used critical thinking to break down problems, evaluate solutions and make decisions.
Customer Service Advocate
UnitedHealth Group
11.2014 - 10.2016
- Assist pharmacies and members on all issues related to processing of pharmacy claims
- Determines appropriateness of overriding pharmacy claims edits and error messages.
- Coordinates internal resolution of claims exceptions and other issues.
- Educates customers on benefits, use of plan, formulary, premiums and status of orders, claims or inquiries.
- Promoted superior experience by addressing customer concerns, demonstrating empathy, and resolving problems swiftly.
- Supported call center associates by taking on escalated calls, handling complex concerns and achieving customer satisfaction targets.
- Participated in regular performance evaluations, consistently exceeding expectations in key metrics such as first-call resolution rate.
- Managed high call volume during peak hours, prioritizing urgent cases while maintaining attention to detail.
- Enhanced customer satisfaction by promptly addressing and resolving inquiries and issues.
Customer Service Representative
State Farm Insurance
05.2012 - 10.2014
- Handled incoming calls from policyholders, responding to inquiries, resolving problems, and correcting policy
- Officially commended for initiative, enthusiasm, tenacity, persuasiveness, intense customer focus and dependability in performance evaluation
- Reduced errors in claim submissions by providing clear guidance to policyholders on required documentation and information needed for processing.
- Ensured accurate documentation and record-keeping, adhering to company policies and industry regulations.
- Enhanced customer satisfaction by efficiently resolving claims and addressing policyholder concerns.
- Streamlined claims processing for quicker resolutions, utilizing thorough investigation techniques and attention to detail.
- Gained valuable insights into customer needs through active listening skills, enabling tailored recommendations for additional coverage options that align with their specific requirements.
- Developed strong relationships with clients, fostering trust and loyalty through exceptional customer service.
- Documented customer interactions and transactions for accurate, up-to-date records.
- Completed customer applications and updated records to reflect current information.
Server
Brookdale Senior Living
01.2004 - 09.2011
- Highly organized and personable supervisor with experience providing exceptional customer service in a fine-dining establishment.
- Assisted team members when necessary in handling cash registers, organizing inventory room, labeling products, unloading merchandise, and cleaning up.
- Success multitasking while remaining professional and courteous in fast-paced environments.
- Exceptional interpersonal team building skills with an aptitude for building rapport with diverse range of customers, managers, and colleagues; talent for quickly resolving issues prior to escalation.
Education
Diploma -
Samuel W. Wolfson High School
Jacksonville, FLSkills
- Claims Investigation
- Claims Processing
- Legal Compliance
- Policy Interpretation
- Highly motivated
- Caseload Management
- Insurance policy coverage knowledge
- Advanced oral and written communication skills
- Advanced computer skills
- Quality Control
- Innovation and Creativity
- Best Practices Implementation
- Critical Thinking
- Computer Skills
- Customer service and support
- Team Collaboration
- Claims
- Active Listening
- Decision-Making
- Relationship Building
- Claims adjustment
- Claims Evaluation
- Coaching and Mentoring
- MS Office
- Fraudulent Claims Investigation
- Data Analysis
- Policy investigations
- Regulatory Compliance
- Policy analysis
Timeline
Claims Adjustment Specialist
UnitedHealth Group
10.2016 - Current
Customer Service Advocate
UnitedHealth Group
11.2014 - 10.2016
Customer Service Representative
State Farm Insurance
05.2012 - 10.2014
Server
Brookdale Senior Living
01.2004 - 09.2011
Diploma -
Samuel W. Wolfson High School
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