ANNA RIVERA
Gainesville
Summary
Dedicated Claims Escalation Specialist with demonstrated success in improving case resolution times and customer satisfaction at UnitedHealthcare. Combines strong problem-solving, communication, and organizational skills to manage competing priorities effectively. A collaborative team player with a results-driven mindset, committed to operational efficiency and delivering high-value service.
Overview
14
14
years of professional experience
Work History
Claim ADJUSTMENT Specialist
UNITED HEALTHCARE (ACQUIRED BY SBI, 2021
Plantation
09.2021 - Current
- Managed 90+ claims daily, ensuring prompt and accurate resolutions to enhance customer satisfaction.
- Investigated complex or denied claims to clarify coverage issues and support fair outcomes.
- Interpreted policy language to determine coverage applicability to specific cases.
- Sustained quality scores of 98-100% in audits through diligent work.
- Identified recurring issues and recommended process improvements to streamline claims handling.
Claim Escalation Specialist
SOLSTICE BENEFITS, INC.
Plantation
03.2021 - 09.2021
- Resolved complex escalated claims and complaints, improving issue resolution turnaround times.
- Communicated with leadership regarding high-priority cases to ensure timely decision-making.
- Identified trends and implemented process improvements, increasing operational efficiency.
- Maintained updated knowledge of industry regulations and company policies affecting escalations.
- Trained new employees on procedures and best practices, ensuring consistent performance standards.
Provider Relations Specialist Claims Liaison
SOLSTICE BENEFITS, INC.
Plantation
01.2019 - 03.2021
- Developed strong relationships with providers to ensure contract compliance.
- Resolved complex disputes between providers and organization through effective problem-solving strategies.
- Collaborated with internal departments to promptly address and resolve provider issues.
- Trained personnel on provider relations policies and procedures to enhance compliance and performance.
- Identified areas for improvement within organizational-provider relationships to enhance collaboration.
- Analyzed data to identify trends in provider performance for continuous improvement.
- Implemented process improvements to streamline provider relations activities and enhance efficiency.
- Generated performance metrics reports for management to support data-driven strategic decisions.
Dental Claims Processor
SOLSTICE BENEFITS, INC.
Plantation
01.2018 - 01.2019
- Reviewed and processed dental claims quickly and accurately according to established guidelines.
- Executed quality assurance checks on submitted claims, ensuring accuracy and compliance.
- Resolved complex billing disputes through effective problem-solving techniques, enhancing claim processing accuracy.
- Analyzed patient eligibility for insurance coverage, verifying accuracy of information prior to processing claims.
- Applied knowledge of CPT codes and ICD-10 coding systems during review process.
- Cultivated relationships with internal stakeholders by delivering timely and informative responses to inquiries.
- Compiled data for reports detailing trends in dentistry costs and utilization rates.
- Implemented innovative strategies that improved overall efficiency of the department's workflow.
- Assisted in training new staff members on proper procedure for submitting dental claims.
- Collaborated regularly with colleagues from different departments in order to resolve issues quickly.
- Resolved complex claim issues through research and collaboration with other departments.
- Leveraged advanced computer skills to navigate various software programs used in processing dental claims.
- Reviewed insurance policy details to confirm patient coverage before processing claims.
- Documented detailed notes about each claim for accurate tracking purposes.
- Transcribed data from various sources to worksheets and entered it into the computer for document preparation and account adjustments.
Claim Administrator
SOLSTICE BENEFITS, INC.
Plantation
10.2012 - 01.2018
- Gained thorough understanding of claims process, effectively reviewing complex claim data to ensure accuracy.
- Maintained accurate records for each claim file in compliance with departmental guidelines.
- Coordinated with departments and vendors, resolving claim issues promptly to maintain workflow.
- Evaluated incoming documents for accuracy before submitting claims.
- Utilized strong organizational skills to ensure timely processing of all claims.
- Collaborated with department leads and management to streamline operations and implement improvements.
- Identified and rectified discrepancies between documentation and coverage limits, ensuring compliance and accuracy.
Education
Bachelor's Degree - Digital Photography
Art Institute of Fort Lauderdale
Florida05-2017
High School Diploma -
Piper High School
Florida05-2012
Skills
- Claims Investigation & Resolution
- Payment Accuracy & Denial Review
- Policy & Contract Interpretation
- Regulatory Compliance
- Process Improvement
- Data Analysis & Reporting
- Escalation Management
- Microsoft Office, Salesforce
- Customer Relations & Conflict Resolution
References
References available upon request.
Quality Scores
- 99.95%
- 100.00%
- 99.00%
- 99.39%
- 98.00%
- 97.00%
- 98.99%
- 96.00%
- 99.36%
Additional Experience
- Team Lead Associate – Old Navy
- Medical Assistant – Pompano Beach Internal Medicine
- Cashier Team Leader – Levi’s Outlet
- HR Clerk – The Continental Group
Timeline
Claim ADJUSTMENT Specialist
UNITED HEALTHCARE (ACQUIRED BY SBI, 2021
09.2021 - Current
Claim Escalation Specialist
SOLSTICE BENEFITS, INC.
03.2021 - 09.2021
Provider Relations Specialist Claims Liaison
SOLSTICE BENEFITS, INC.
01.2019 - 03.2021
Dental Claims Processor
SOLSTICE BENEFITS, INC.
01.2018 - 01.2019
Claim Administrator
SOLSTICE BENEFITS, INC.
10.2012 - 01.2018
Bachelor's Degree - Digital Photography
Art Institute of Fort Lauderdale
High School Diploma -
Piper High School