Summary
Overview
Work History
Education
Skills
Certification
Military Service
Timeline
Generic

Cleon Harris

Jacksonville,United States

Summary

Professional with comprehensive experience in claims processing and evaluation. Demonstrates strong analytical skills, thorough knowledge of insurance policies, and consistent track record of identifying and resolving complex claims. Valued team player with strong focus on collaboration and results, adaptable to evolving work environments. Known for reliability, problem-solving abilities, and effective communication with stakeholders.

Overview

13
13
years of professional experience
1
1
Certification

Work History

Claims Examiner I

THE DAVIES GROUP
04.2024 - Current
  • Ensure claim data entry is accurate and timely, in alignment with departmental production and quality goals.
  • Manually price and adjudicate claims as needed, while maintaining a minimum of 98% accuracy.
  • Apply policies and procedures to confirm that claims meet the criteria for payment and are in compliance with MBA contractual guidelines.
  • Handled sensitive information with discretion, ensuring confidentiality of personal and financial details for claimants throughout the claims examination process.
  • Analyze the policy terms to assess whether the claim falls within the insured events and coverage limits.
  • Identify potential fraudulent claims by looking for inconsistencies or suspicious patterns.
  • Ensure compliance with regulatory standards, company policy, and guidelines.
  • Assist claims adjusters to manage large volumes of cases.
  • Utilized analytical skills to evaluate medical bills for accuracy and appropriateness of charges before approving payments as part of the claims process.

Claims Resolution Representative II

Liberty Mutual Insurance
06.2022 - 09.2023
  • Responsibilities include investigation, analysis, and other claims handling duties for easy to medium severity auto loss claims within assigned authority limits and consistent with policy and legal requirements
  • Used a variety of internal and external resources, problem-solving techniques, and sound claims judgment to assist customers across the United States
  • While working a caseload of 40 claims with one to three exposures per claim
  • Investigated and determined appropriate coverage for auto claims through in-house software, and virtual tools
  • Collaborated with teammates using Microsoft Teams, Excel, and Word
  • While providing exceptional customer service throughout the life cycle of the claim
  • Determined policy coverage, set reserves, and determined whether the claim would be approved or denied, including recommendations made by independent and/or field adjustors
  • Worked with and coordinated several vendor services, according to the appropriate coverage, such as contractors, experts, emergency repair, towing, cleaning services, and various replacement services, while ensuring the customer was appropriately communicated with changing events
  • Maintained accurate and current claim file documentation throughout the life cycle of the claim
  • Reviewed all claims for possible referral to SIU and submitted where appropriate
  • Closed claim files upon completion of final payment
  • Would collaborate with peers in all aspects of adjusting and provide feedback to temporary adjustors.

Field Representative-Third Party Liability

MedData
10.2019 - 03.2022
  • Determined policy coverage, set reserves, and determined whether the claim would be approved or denied, including recommendations made by independent and/or field adjustors.
  • Worked with and coordinated several vendor services, according to the appropriate coverage, such as contractors, experts, emergency repair, towing, cleaning services, and various replacement services, while ensuring the customer was appropriately communicated with changing events.
  • Maintained accurate and current claim file documentation throughout the life cycle of the claim. Reviewed all claims for possible referral to SIU and submitted where appropriate.
  • Closed claim files upon completion of final payment. would collaborate with peers in all aspects of adjusting and provide feedback to temporary adjustors.

Care Management Coordinator I

One Call Care Management
03.2017 - 11.2018
  • Performed nonclinical coaching and consultation with patients and their caregivers in conjunction with Nurse Care Navigators, as well as managed and transitioned patients under the Medicare Bundle Payment Program.
  • Performed healthcare coordination with patients and their caregivers who need assistance understanding their service provider options, benefits, available resources, and financial impact of care decisions.
  • Developed strong working knowledge of resources within the local community to reintegrate the patient and facilitate the transferring of the patient back into their community for post-acute continued care.
  • Worked within Medicare regulations, using reimbursement methodologies within care settings including inpatient rehabilitation, outpatient, home health and skilled nursing facilities.
  • Coordinated and managed 40 transitional cases at all times using the internal system of care model to ensure quality and cost-effective care and to reduce risk of readmission.
  • Developed and maintained external relationships with representatives in healthcare and social organizations throughout the local and regional communities to support patients in obtaining home health and community based social services.
  • Exceed quality standards by maintaining flexibility and adaptability while handling patient/caregiver and staff concerns. Exceptional ability to multitask, as well as work under pressure in a fast-paced setting.
  • Conducted follow up calls to patient's after discharge to home as well as periodic home visits to deliver supplies, equipment and to provide social support.
  • Marketing strategies utilized (value and brand recognition, case studies) to promote the use of wearable devices over the period of six months while in the complete care program.
  • Utilized Fitabase and Excel to track and monitor research data (steps, heart rate, utilization, etc.) for 24 patients, as well as conducted follow up question and data collection after the research period ended using follow up calls, emails and traditional mail.
  • Promoted research study to patients using internal marketing techniques, and trained patients on the use of the Fitbit watch as well as the installation, use, and troubleshooting of the Fitbit application.
  • Provided monthly training to new employees on the complete care program and employee responsibilities within the program.
  • Performed periodic presentations to senior staff and executives on bundle pay initiatives and departmental changes in relation to research data, patient status, and patient satisfaction.

Care Navigator Coach

10.2014 - 03.2017
  • Facilitated the flow of evaluations, orders, and progress notes from providers to Adjusters or Nurse Case Managers.
  • Reviewed doctors' orders, initial assessments, and evaluations as well as leveraged strong customer service and communication skills to highlight changes in status, and projected needs of the patient to their provider and carrier.
  • Utilized internal tracking tools as well as Microsoft Outlook, Microsoft Word, and Excel to ensure timely follow up and reporting on critical timelines and issues as outlined in company policies.
  • Used internal systems to locate providers that met the operational and timely needs of a specific referral throughout the region.
  • Conducted pricing negotiations with providers throughout the country for real time referrals.
  • Actively managed 40-55 ongoing and transitional cases located throughout the United States, while maintaining a Quality Assurance Score of 100%.
  • Ensured company profitability through accurate calculations of fee schedule-based vendor pricing for all services to include home health, durable medical equipment, transportation, medications, and miscellaneous services and supplies.
  • Drafted initial, change of condition, and monthly detailed executive patient summaries to serve as a clinical overview reference report for the insurance adjusters and nurse case managers.

Laboratory Assistant II

Baptist Primary Care
06.2012 - 10.2014
  • Handled hazardous materials responsibly following proper waste disposal procedures to minimize environmental impact.
  • Actively participated in lab safety inspections, identifying potential hazards and implementing corrective actions promptly.
  • Successfully completed specialized testing procedures while balancing normal daily workflow requirements.
  • Facilitated collection of blood & fluid samples from patients, utilizing appropriate collection procedures.
  • Enhanced lab safety measures by conducting regular equipment maintenance and implementing updated protocols.
  • Served as a reliable source of information for colleagues seeking assistance or clarification on laboratory procedures or equipment use.
  • Maintained accurate and up-to-date laboratory records, ensuring compliance with institutional guidelines and facilitating audits when necessary.
  • Trained new laboratory personnel on standard operating procedures, ensuring consistent performance across team members.
  • Managed inventory levels effectively by tracking supply usage and placing orders for required materials before depletion.
  • Developed new protocols and improved existing laboratory processes.

Education

Bachelor of Science (B.S.) - Health Administration

University of Phoenix

Skills

  • Effective time management
  • Client support
  • Effective organizational skills
  • Dispute resolution
  • Regulatory compliance expertise
  • Proficient in oral and written communication
  • Claims analysis
  • Policy analysis
  • Proficient in advanced computer applications
  • Effective caseload management
  • Data validation
  • Effective verbal communication
  • Claims management

Certification

Adjuster-All Lines 0620, 2022-02-01, 2024-10-31

Military Service

United States Navy, United States, 1999-07-01, 2016-10-31

Timeline

Claims Examiner I

THE DAVIES GROUP
04.2024 - Current

Claims Resolution Representative II

Liberty Mutual Insurance
06.2022 - 09.2023

Field Representative-Third Party Liability

MedData
10.2019 - 03.2022

Care Management Coordinator I

One Call Care Management
03.2017 - 11.2018

Care Navigator Coach

10.2014 - 03.2017

Laboratory Assistant II

Baptist Primary Care
06.2012 - 10.2014

Bachelor of Science (B.S.) - Health Administration

University of Phoenix

Similar Profiles

CREATE PROFILE