Ariel Gooden
Tampa,FL
Summary
I am friendly, loyal and clearly dedicated individual who has an ambition to succeed in any given environment. I love to learn, and am always up to a challenge whatever the situation, I get along well with others, with also working efficiently on my own. I am seeking a position where I can develop and excel while giving my best to an employer. Skilled Account Supervisor ready to pursue new professional challenges in the healthcare industry. Successful at overseeing diverse customer projects with a quality-driven mindset. Top skills include team leadership, coordination and planning. Analytical Claims Specialist with proven experience investigating and resolving property, health and business claims. Delivers professional and balanced customer service and meets needs of insured, claimant and internal and external customers. Insurance expert with exceptional knowledge of legal liabilities and claims practices and superior interpersonal skills.
Overview
16
16
years of professional experience
Work History
Grievance Appeals Specialist
Humana
10.2021 - Current
- 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
- Claims Investigation
- Customer Service
- Conflict Resolution
- Time Management
- Attention to Detail
- Critical Thinking
- Problem Solving
- Regulatory Knowledge
- Data Entry
- Report Writing
- Documentation Management
- Communication Skills
Licenses
Florida 6-20 All-Lines Adjuster License (Active)
Licensed to handle insurance claims across multiple lines, including property, casualty, commercial, and liability. Authorized to investigate, evaluate, negotiate, and settle claims in compliance with Florida insurance regulations. Knowledgeable in policy interpretation, claims processes, and customer service best practices. Eligible to work independently or as a staff adjuster without supervision.
Timeline
Grievance Appeals Specialist
Humana
10.2021 - Current
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
Similar Profiles
Ja'nericka CunninghamJa'nericka Cunningham
Customer Care Specialist at HumanaCustomer Care Specialist at Humana
Lindsey WilsonLindsey Wilson
Grievance & Appeals Representative 3 at HumanaGrievance & Appeals Representative 3 at Humana
Perla OrtegaPerla Ortega
Finance Mail Operations Pharmacy Technician II at HumanaFinance Mail Operations Pharmacy Technician II at Humana
Stephanie R. ReeseStephanie R. Reese
Billing/Payment Recovery Specialist at HumanaBilling/Payment Recovery Specialist at Humana
ANGEL ROSIERANGEL ROSIER
Cosmetologist at Mimie's House of Beauty SuitesCosmetologist at Mimie's House of Beauty Suites