Ariel Gooden
Tampa,FL
Summary
Demonstrated friendliness, loyalty, and dedication in various environments. Embraced learning opportunities and effectively tackled challenges. Collaborated well with teams while maintaining the ability to work independently. Seeking a position to grow and contribute optimally to an organization. Facilitated account supervision, ready to explore new roles in the healthcare sector. Managed diverse customer projects with a focus on quality. Key competencies include team coordination, leadership, and planning. Investigated and resolved property, health, and business claims as an analytical claims specialist. Provided balanced customer service and fulfilled the needs of insured claimants and both internal and external customers. Possessed extensive knowledge of legal liabilities and claims practices with strong interpersonal skills.
Overview
16
16
years of professional experience
Work History
Claims Adjuster
Zelis Healthcare
Tampa, FL
02.2023 - Current
- Evaluated and processed insurance claims to ensure compliance with policies and regulations.
- Investigated complex claims cases, collaborating with stakeholders to gather necessary documentation.
- Analyzed claim data to identify trends and potential fraud, enhancing risk mitigation strategies.
- Trained and mentored junior adjusters on best practices in claims assessment and customer service.
- Developed training materials for new hires, enhancing onboarding efficiency and knowledge retention.
- Examined claims forms and other records to determine insurance coverage.
- Verified insurance claims and determined fair amount for settlement.
- Maintained compliance with state regulatory requirements through meticulous documentation and adherence to company policies.
- Conducted thorough investigations of complex insurance claims, gathering evidence and analyzing relevant documentation.
Grievance Appeals Specialist
Humana
10.2021 - 02.2023
- Developed appeals functions, policies and procedures and documentation.
- Coordinated with senior specialist to compose appeal responses.
- Acted as a departmental resource on appeals matters.
- Responded to attorney inquiries and litigation notices.
- Created, composed and maintained appeal response templates.
- Calculated adjustments, premiums and refunds.
- Reviewed outstanding requests and redirected workloads to complete projects on time.
- Communicated effectively with staff members of operations, finance and clinical departments.
- Made contact with insurance carriers to discuss policies and individual patient benefits.
- Generated, posted and attached information to claim files.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
- Carried out administrative tasks by communicating with clients, distributing mail, and scanning documents.
- Posted payments to accounts and maintained records.
- Maintained confidentiality of patient finances, records, and health statuses.
Account Supervisor
Humana
10.2020 - 10.2021
- I represent the company by addressing incoming telephone, digital, or written inquiries
- I also perform varied activities and moderately complex administrative/operational/customer/ support assignments.In addition to the many tasks that I performed I also handled escalated calls from angry and abusive callers
- I was part of filing and resolving grievances and appeals.
Claims Specialist
Humana
03.2019 - 11.2020
- Processed payments for valid claims according to established procedures.
- Researched medical records to evaluate claim validity and verify the existence of pre-existing conditions.
- Investigated complex or high-value claims to identify discrepancies and fraud indicators.
- Reviewed and analyzed insurance claims to determine validity, completeness, accuracy, and eligibility for payment.
- Compiled data from multiple sources for reporting purposes.
- Assisted with filing appeals on denied claims with insurance companies.
- Maintained detailed records of all claim activities including notes about conversations with claimants or representatives.
- Resolved claims by approving or denying documentation, calculating benefits due and determining compensation settlement.
- Planned and conducted investigations of claims to confirm coverage and compensability.
- Documented specific claims by completing and recording forms, reports and logs.
Pharmacy and Web Specialist
Humana
11.2018 - 03.2019
- Addresses customer needs which may include complex benefit questions, resolving issues and educating members
- Records details of inquiries, comments or complaints, transactions or interactions and takes action in accordance to it
- Escalates unresolved and pending customer grievances
- Assist members with creating online accounts, resetting passwords and navigating members through the web
- Provide pharmacy benefit information to members like copays and drug coverage.
Billing Specialist
Quest Diagnostics
04.2014 - 11.2018
- Reviewed medical records to ensure accuracy of billing information and patient data.
- Prepared itemized statements, bills, or invoices and recorded amounts due for items purchased or services rendered.
- Monitored accounts receivable activity to ensure timely payment of invoices.
- Resolved discrepancies between customers' remittances and invoices received.
- Answered customer inquiries regarding billings, payments, account status.
- Maintained accurate records of collections, adjustments and denials in the system.
- Processed credit card transactions through Point-of-Sale terminals or online systems.
- Generated periodic reports summarizing account balances and collection activities.
Customer Care Rep1/Client Services Rep
Quest Diagnostics
03.2010 - 04.2014
- Handles all customer inquiries by telephone regarding verbal reporting of results, concerns of service failures and other duties to provide customer satisfaction
- Reports laboratory results to clients using established protocols
- Documents reporting or call history in the patient's file and maintain appropriate records
- Contacts the client to resolve routine matters related to patient testing and result reporting
- Uses established protocols for reporting client concerns
- Other duties as required to meet the customer requirements
- Understands the importance of Quality Service and how it is measured.
- Assessed customer needs and responded to inquiries in a timely manner.
- Provided technical support for clients, troubleshooting issues and resolving complaints.
- Developed relationships with customers through proactive communication and follow-up.
Skills
- Quality Controls
- Strategic Planning
- Production Support
- Quality Assurance
- Complaint Resolution
- Performance Evaluation
- Loan Servicing
- Loan Origination
- Customer Relations
- Automated Underwriting System (AUS)
Timeline
Claims Adjuster
Zelis Healthcare
02.2023 - Current
Grievance Appeals Specialist
Humana
10.2021 - 02.2023
Account Supervisor
Humana
10.2020 - 10.2021
Claims Specialist
Humana
03.2019 - 11.2020
Pharmacy and Web Specialist
Humana
11.2018 - 03.2019
Billing Specialist
Quest Diagnostics
04.2014 - 11.2018
Customer Care Rep1/Client Services Rep
Quest Diagnostics
03.2010 - 04.2014