Felicia Nelson
North Las Vegas,NV
Summary
Dynamic claims processing and customer service professional with extensive experience at Liberty Dental Plan. Demonstrated expertise in Salesforce and Meditrac, achieving a 30% increase in operational efficiency. Known for strong problem-solving skills and a commitment to empathy, effectively resolving conflicts and enhancing customer satisfaction. Proven ability to streamline processes and drive positive business outcomes.
Overview
15
15
years of professional experience
Work History
PAP Counselor
Regalo Rx
Overland Park, KS
10.2024 - 11.2024
- Answered incoming calls promptly, courteously, and professionally.
- Adhered to all HIPAA regulations regarding patient privacy and confidentiality.
- Utilized pharmacy management software to input patient data and process insurance claims.
Claims Specialist
Liberty Dental Plan
Las Vegas, NV
12.2020 - 10.2024
- Provided technical guidance and training to new staff members regarding claim processing procedures.
- Adhered to all applicable laws, regulations, and company standards while processing claims.
- Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
Claims Assistant
Ajilon Staffing Agency
Las Vegas, NV
12.2019 - 03.2020
- Collected payments, processed receipts and informed policyholders of outstanding balances.
- Monitored electronic claims submissions and bad debt write-offs.
- Analyzed claims data to identify trends and recommend changes to reduce risk and prevent fraud.
Volunteer
Ronald McDonald House
Las Vegas, NV
10.2018 - 02.2020
- Built partnerships with related organizations to develop support and gain greater attention for important issues.
- Assisted with fundraising efforts, including event planning and donor outreach.
- Collaborated with others by contributing time, effort and skills to achieve the organization's goals.
Claims Representative
Progistics Distribution
Las Vegas, NV
10.2018 - 02.2019
- Corresponded with insured or agent to obtain information or inform of account status or changes.
- Assisted new policyholders with processing claims.
- Negotiated settlements with claimants and attorneys to resolve claims efficiently and fairly.
Claims Adjuster
CLEVELAND CLINIC FOUNDATION
Cleveland, OH
06.2012 - 10.2018
- Calculated and authorized payment of claims within designated authority level.
- Negotiated settlements with claimants or their representatives in order to resolve disputes quickly and economically.
- Conducted witness interviews to assist claim information gathering process.
Contact Center Representative
University Hospitals
Cleveland, OH
06.2013 - 11.2015
- Answered, screened and processed high volume of calls daily with call management system and web-based communications.
- Maintained call logs and records of customer interactions using CRM software.
- Consulted with customers to resolve service and billing issues.
Prior Authorization Coordinator
AreaTemps
Cleveland, OH
08.2009 - 05.2012
- Reviewed and verified financial data to determine program eligibility.
- Processed appeals in a timely manner as per policy guidelines.
- Input claim, prior authorization, and other important medical data into system.
Education
Certificate - Business
Whitney M. Young Jr. Job Corps Center
Simpsonville, KY01-1989
High School Diploma -
Collinwood High School
Cleveland, OH06-1987
Some College (No Degree) - Business Administration
University of Phoenix
Las Vegas, NVSkills
- Salesforce Management Skills
- Conduent-Meditrac Experience
- Microsoft Proficiency
- Pharmacy: Medical Claims Processing
- Workers' Compensation Claims Processing
- Epic Management
- Referral Authorization Processing
- Helpdesk support
- Troubleshooting
- Conflict resolution
- Active listening
- Empathy
- Problem solving
- Medical terminology
References
References and additional employment history available upon request.
Highlightsandskills
- Customer Service Representative
- Processed Dental Claim inquiries for DHMO/PPO/EPO/GOVERNMENT/WC products
- Performed eligibility/benefits verification, documentation of client’s information, HIPPA authentication utilizing Salesforce-CRM, Conduent-Meditrac, Microsoft, Macess tools
- Proficient processing Level I and II grievances and appeals in customer’s escalations and Medicaid/Medicare/Commercial product guidelines
- Audited referral processing/insurance coverage data entry accuracy utilizing Allscripts, AS400 applications
- Processed client pharmacy, medical and worker’s compensation claims in Epic and referral/prior authorization approvals/denials processing for financial clearance in Facets
- Creating helpdesk tickets, troubleshooting, and resolving Level 1 provider/member web portal issues
- Effectively handled angry/frustrated customers by actively listening, showing empathy, using positive and providing solutions to resolve issues without escalating the situation further
Timeline
PAP Counselor
Regalo Rx
10.2024 - 11.2024
Claims Specialist
Liberty Dental Plan
12.2020 - 10.2024
Claims Assistant
Ajilon Staffing Agency
12.2019 - 03.2020
Volunteer
Ronald McDonald House
10.2018 - 02.2020
Claims Representative
Progistics Distribution
10.2018 - 02.2019
Contact Center Representative
University Hospitals
06.2013 - 11.2015
Claims Adjuster
CLEVELAND CLINIC FOUNDATION
06.2012 - 10.2018
Prior Authorization Coordinator
AreaTemps
08.2009 - 05.2012
Certificate - Business
Whitney M. Young Jr. Job Corps Center
High School Diploma -
Collinwood High School
Some College (No Degree) - Business Administration
University of Phoenix
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