Gaetan Nelson
Orlando,FL
Summary
Efficient and productive Claims Specialist known for swiftly and accurately managing claims processes. Specialize in policy interpretation, negotiation, and settlement strategies which streamline operations and improve turnaround times. Possess strong analytical skills, fraud detection capabilities, and knowledge of insurance regulations. Excel in communication, problem-solving, and organizational skills to effectively handle multiple claims simultaneously while maintaining high satisfaction levels among all parties involved.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Claims Specialist
Blue Cross Blue Shield
Orlando, US
09.2023 - 01.2026
- Managed high-volume caseload of complex specialty pharmacy insurance claims from intake to resolution.
- Conducted thorough investigations of medical documentation and policy coverage criteria for claim eligibility.
- Evaluated coverage exposure, identifying denial risks and implementing strategies to mitigate financial impact.
- Communicated formal coverage determinations and claim decisions to patients and prescribers for clarity.
- Collaborated with compliance teams and payer representatives to resolve escalated disputes and appeals.
- Monitored claim progression, proactively managing follow-ups to minimize turnaround time.
- Provided analytical support regarding recurring denial trends and workflow inefficiencies to leadership.
- Possessed 2-3 years of experience in medical collections denials and appeals across various categories.
Insurance Claims Specialist
Cigna
Orlando, US
02.2022 - 07.2023
- Processed and updated insurance and disability claims in case management systems to ensure accuracy.
- Contacted claimants to provide status updates and clarify documentation requirements while maintaining confidentiality.
- Reviewed open claims, tracking progress to ensure compliance with company and federal guidelines.
- Served as liaison among carriers, claimants, and internal teams to resolve issues efficiently.
- Supported training sessions and special projects aimed at implementing process improvements for enhanced efficiency.
Member representative / fraud detection representative
Alegeus technologies
Orlando, US
03.2021 - 01.2022
- Acquired knowledge of HSA, HRA, FSA, and DCA accounts to support client needs
- Took calls for multiple clients including American Fidelity, First Financial and PayFlex
- Calls were graded with a 92% proficiency rate
- Specialized in Claims for the HSA, DCA and HRA accounts as well
- Investigated and resolved fraudulent claims and inquiries to protect customer accounts
- Monitored accounts with suspected fraud to ensure compliance and security
Data Entry Specialist
Ossur
Orlando, US
05.2021 - 07.2021
- Temporary Data entry project in which I was assisting in custom prosthetic and orthotic orders for disabled customers and patients.
- I was in charge of completing service orders, custom medical orders, returns, replacements, transactions and insurance complications as well as assisting customer via email and over the phone.
Pharmacy Technician
Express Scripts
03.2020 - 10.2020
- Process and verify prescription orders over the phone and electronically
- Provide medication counseling support under pharmacist supervision
- Handle insurance claim submissions, prior authorizations, and billing issues
- Respond to patient and provider inquiries with professionalism and accuracy
- Maintain patient records and ensure HIPAA compliance
- Assist pharmacists with medication dispensing workflow
Control Associate
Biozone Scientific international
Orlando, US
06.2017 - 07.2018
- I assisted in quality control of the products and components.
- I would make sure things like the charge conducted from products was safe and reliable for customers to receive in their shipments.
- This was a Summer job that I picked up the summer of my sophomore year.
- I could only work there in the summer because of the long commute and free time because I wasn't doing any summer programs at the time.
Education
Associate in Arts (AA) - Computer science
Valencia College
10-2023
High school diploma - Upper secondary education
Doctor Phillips high school
05-2020
Skills
- Insurance verification
- Medical terminology
- Medical office experience
- Microsoft Outlook
- Process improvement
- ICD-10
- Computer Science
- Microsoft Office
- Commercial driving
- Warehouse experience
- Communication skills
- Data entry
- Claims trend analysis
- Complex claims consulting
- English
- Customer service
- Interpersonal skills
- Health insurance authorizations
- Microsoft Excel
- Claims investigation
- knowledge of ICD-10, CPT, HCPCS and NCCI
- knowledge of third party billing guidelines
- knowledge of billing claim forms(UB04/1500)
- knowledge of payor contracts- commercial and government
- Working Knowledge of Microsoft Word and Excel
- knowledge of health information systems (ie EMR, Claim Scrubbers, Patient Accounting Systems, etc)
Certification
- Driver's License
- CNA
Personal Information
Work Permit: Authorized to work in the US for any employer
Timeline
Claims Specialist
Blue Cross Blue Shield
09.2023 - 01.2026
Insurance Claims Specialist
Cigna
02.2022 - 07.2023
Data Entry Specialist
Ossur
05.2021 - 07.2021
Member representative / fraud detection representative
Alegeus technologies
03.2021 - 01.2022
Pharmacy Technician
Express Scripts
03.2020 - 10.2020
Control Associate
Biozone Scientific international
06.2017 - 07.2018
Associate in Arts (AA) - Computer science
Valencia College
High school diploma - Upper secondary education
Doctor Phillips high school