Candace Hilton
Covington,GA
Summary
Dynamic and detail-oriented professional with extensive experience at Assurant, excelling in claims processing and customer service. Proven ability to resolve complex issues and educate clients on insurance benefits. Skilled collaborator with a strong command of HIPAA regulations and effective communication, ensuring compliance and enhancing customer satisfaction.
Overview
8
8
years of professional experience
Work History
Customer Care Specialist
Assurant
05.2022 - Current
- Assist customers in understanding their insurance benefits, deductibles, and co-payments.
- Educate customers on available insurance products and services, helping them make informed decisions about their coverage options.
- Provide guidance and support to customers navigating the insurance claim process, including submitting necessary documentation and following up on claim status.
- Resolve customer complaints and issues related to claims processing, billing discrepancies, or policy changes.
- Respond promptly and courteously to customers inquiry regarding insurance policies, claims, and coverage details.
Claims Benefits Specialist
Premier Kids Care Pharmacy
10.2018 - 05.2022
- Review and process pharmacy claims to ensure they are submitted accurately and meet the criteria for coverage.
- Verify claims data for completeness, accuracy, and consistency with insurance policies, formulary, and benefit plans.
- Review pharmacy billing and prescription claims to ensure compliance with contractual terms and conditions.
- Research and resolve rejected or denied claims, ensuring accurate payment or denial based on policy terms.
- Work with pharmacies, insurance providers, and patients to resolve issues, explain claims decisions, and provide guidance on necessary documentation for claim reprocessing.
- Use the QNXT system to manage claims, perform data entry, and ensure records are updated in real time.
Claim Examiner
Teleperformance
11.2017 - 10.2018
- Analyze submitted insurance claims (health, auto, life, disability, etc.) for accuracy and completeness.
- Check documentation (e.g., police reports, medical records, or invoices) to confirm facts and policy coverage.
- Assess if the claim meets policy conditions and whether benefits should be paid.
- Look into potential fraud or discrepancies.
- Contact claimants, healthcare providers, or other parties for clarification or additional information.
- Approve, deny, or escalate claims for further investigation.
Education
High School Diploma -
Jefferson County High
Louisville, GA05-2006
Skills
- Skilled collaborator
- Claims processing
- Insurance knowledge
- Customer service
- Data entry
- Effective communication
- Attention to detail
- Document management
- Intermediate level of proficiency with PC and Windows applications
- Health and safety management
- HIPAA
Timeline
Customer Care Specialist
Assurant
05.2022 - Current
Claims Benefits Specialist
Premier Kids Care Pharmacy
10.2018 - 05.2022
Claim Examiner
Teleperformance
11.2017 - 10.2018
High School Diploma -
Jefferson County High
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