Crystal Whitaker
Lauderhill,FL
Summary
Claims professional with over 4 years of experience adjudicating high volume medical claims in remote payer environments. Experienced in EOB analysis, provider communication, eligibility verification, and resolving complex claims in accordance with payer policies and regulatory guidelines. Proven ability to meet strict productivity and quality metrics while delivering accurate claim determinations and maintaining strong provider relationships. Skilled in navigating CMS-1500 and UB-04 claims, supporting appeals, and ensuring compliant reimbursement processes aligned with healthcare payer standards.
Overview
8
8
years of professional experience
Work History
Claim Benefit Specialist
VXI Global Solutions
Remote
07.2022 - 07.2025
- Examined and adjudicated high volume medical claims using CMS-1500 and UB-04 forms ensuring accurate payment decisions aligned with health plan policies.
- Conducted provider outreach to resolve disputed or negotiable claims and supported cost containment efforts prior to payment.
- Resolved appeals, disputes, and post closure claim inquiries while maintaining documentation accuracy and quality scores above 98%.
- Met strict SLA productivity targets while handling complex claim scenarios in a remote claims environment.
Claims Examiner
Sagility
Remote
01.2019 - 12.2020
- Reviewed and processed medical claims by verifying member eligibility, coverage, and provider network participation.
- Applied ICD-10, CPT, and HCPCS coding standards to validate billed services and ensure accurate reimbursement.
- Analyzed EOB’s to identify discrepancies and prevent overpayments.
- Collaborated with internal teams to investigate and resolve complex claim issues and appeals.
Claims Processor
United Healthcare
Remote
07.2017 - 01.2019
- Processed medical claims in compliance with payer policies, eligibility guidelines, and regulatory standards.
- Reviewed CMS-1500 and UB-04 forms for completeness and benefit alignment before adjudication.
- Verified member eligibility and provider participation.
- Investigated claim discrepancies including coding errors, duplicates, and missing documentation.
- Calculated reimbursements using fee schedules, contract terms, and plan rules.
- Prepared documentation supporting claim appeals and dispute resolutions.
Education
High School Diploma -
John I. Leonard High School
Greenacres, FL05-2005
Skills
- Medical Claims Processing & Adjudication
- CMS-1500 and UB-04 Claims Review
- CPT, ICD/10 & HCPCS Coding Knowledge
- EOB Analysis & Coverage Determination
- Appeals, Reconsiderations & Denial Resolution
- Provider & Member Communication
- Eligibility Verification
- Policy & Fee Schedule Interpretation
- HIPAA Compliance
- High Volume Claims Queue Management
- Audit Ready Documentation & Quality Assurance
- 10 Key Typing (60 WPM)
Timeline
Claim Benefit Specialist
VXI Global Solutions
07.2022 - 07.2025
Claims Examiner
Sagility
01.2019 - 12.2020
Claims Processor
United Healthcare
07.2017 - 01.2019
High School Diploma -
John I. Leonard High School