Dakota Heller
Dania Beach,FL
Summary
Experienced and detail-oriented Claims Specialist with a strong track record of managing diverse claims in remote environments. Adept at evaluating claim accuracy, resolving discrepancies, and ensuring regulatory compliance. Skilled in handling complex inquiries, negotiating settlements, and delivering high-quality customer support. Recognized for efficiency, precision in documentation, and consistently exceeding performance targets.
Overview
6
6
years of professional experience
Work History
Senior Virtual Claims Specialist
The Cigna Group
Remote
02.2022 - Current
- Adjudicated over 150 complex claims weekly, using CMS guidelines and clinical data.
- Verified member eligibility and resolved policy discrepancies to ensure accurate processing.
- Investigated appeals and reconsiderations, resolving 95% of them within 48 hours.
- Analyzed medical records and collaborated with providers to clarify documentation.
- Identified and referred suspected fraud, reducing fraudulent claim payments.
- Recovered over $20,000 through the correction of overpayments and underpayments.
- Maintained HIPAA-compliant documentation, and supported audit readiness.
- Trained and mentored junior staff, improving onboarding efficiency by 30%.
- Implemented process improvements, accelerating claim disbursal, and boosting satisfaction.
- Prepared reports and resolution recommendations for leadership.
Senior Benefits Specialist
Milliman
Remote
07.2019 - 02.2022
- Reviewed eligibility for medical insurance coverage and other benefit plans.
- Maintained records of employee participation in various benefits programs.
- Assisted employees with enrolling in benefit plans and explained plan options.
- Provided guidance on claims processing procedures to ensure timely payments.
- Processed invoices from vendors providing services related to benefit administration.
- Processed benefit enrollment forms, changes, and terminations.
- Performed audits of existing policies and procedures to identify areas for improvement.
Education
BACHELOR OF APPLIED SCIENCE - DATA ANALYTICS & AI
Broward College
Fort Lauderdale01.2027
Skills
- Claims evaluation and processing
- Claims investigation and management
- Policy and coverage analysis
- Settlement calculation and negotiation
- Fraud detection and dispute resolution
- Medical record review and eligibility verification
- HIPAA and regulatory compliance
- Insurance claim forms review
- CRM and claims management software proficiency
- Microsoft Office applications proficiency
- Data entry and process optimization
- Estimate preparation for small claims payouts
- Customer service excellence
Timeline
Senior Virtual Claims Specialist
The Cigna Group
02.2022 - Current
Senior Benefits Specialist
Milliman
07.2019 - 02.2022
BACHELOR OF APPLIED SCIENCE - DATA ANALYTICS & AI
Broward College
Similar Profiles
Leticia NicolaLeticia Nicola
Dedicated Client Service Partner at The Cigna GroupDedicated Client Service Partner at The Cigna Group
Enid Thomas-Wade, CMT, CNA, CPCEnid Thomas-Wade, CMT, CNA, CPC
Senior Grievance Coordinator at The Cigna GroupSenior Grievance Coordinator at The Cigna Group
Ellie PolackEllie Polack
Managing Director at The Cigna GroupManaging Director at The Cigna Group
Michelle DobbsMichelle Dobbs
Business Analytics Lead Analyst at The Cigna GroupBusiness Analytics Lead Analyst at The Cigna Group
Ashley Valdes SigarroaAshley Valdes Sigarroa
Director of Operations and Logistics at Dawa Medical LLCDirector of Operations and Logistics at Dawa Medical LLC