Jamese Town
Lynwood
Summary
Detail-oriented Claims Adjuster with over 4 years of experience specializing in Employment Practices Liability (EPLI) and commercial liability insurance. Expert in evaluating wrongful termination, discrimination, and harassment claims, ensuring compliance with state and federal employment laws. Proven ability to manage high-exposure litigation, collaborate with defense counsel, and resolve claims efficiently, resulting in a 15% reduction in average settlement.
Overview
20
20
years of professional experience
2028
2028
years of post-secondary education
Work History
Claim Adjuster
CNA INSURANCE
Chicago
09.2022 - Current
- Interprets more complex or unusual policy coverages and determines if coverages apply to claims submitted, escalating issues as needed.
- Sets activities, reserves and authorizes payments within scope of authority.
- Ensures issuance of disbursements while managing loss costs and expenses.
- Coordinates and performs investigations and evaluates claims and suits through contact with insureds, claimants, business partners, witnesses and experts.
- Seeks early resolution opportunities.
- Identifies files that have potential fraud and refers to SIU.
- Utilizes negotiation skills to develop complex settlement packages.
- Identifies claims with third party recovery potential and coordinates with subrogation/salvage unit.
- Partners with attorneys, account representatives, agents, underwriters, doctors, nurse case managers and insureds to develop a focused strategy for timely and cost effective resolution of more complex claims.
- Analyzes claims activities.
- Prepares and presents reports for management.
- Taking on the responsibility for special projects and presentations when needed.
- Inputting of data that accurately reflects claim circumstances and other information important to CNA’s business outcomes.
- Handling of Workers Compensation Claims.
- Processing disability claims and documenting claims files and properly coding claims.
CLIENT SERVICES LIAISON-OUT OF NETWORK SERVICES
MULTIPLAN
Remote
09.2021 - 09.2022
- Serve as first point of contact for client and sales specific to Out of Network Solutions (OON) product requests and inquiries required to operationalize the client’s business and exceed client expectations.
- Prioritize, triage, and manage inquiries to ensure timely resolution.
- Receive communication of a client inquiry or request and analyze, research and resolve through effective use of tools and resources.
- Refer escalated cases to appropriate leadership as appropriate.
- Manage and track all client or account management requests, including thorough documentation of the issue/inquiry, research, assignment, risks, deliverables, follow-ups, deadline dates and reporting.
- Operationally assist and communicate with all internal departments on all issues/inquiries.
- Upon resolution assist with documentation and implementation of solutions, to include post deployment warranty monitoring and reporting.
- Proactively identifying ways to improve current processes and work with OON leadership to implement new procedures.
- Keeping departmental leadership aware of pertinent inquiries and requests warranting their knowledge, action or resolution.
- Act as a liaison for account management, client and internal Operations staff by responding to questions specific to interpretation of fundamental reimbursement and appeals activity, and all associated operational workflows in support of delivery of each product and service.
- Handled workers compensation claims- processed disability claims.
CLAIMS BUSINESS ANALYST
CENTENE HEALTHCARE CORP.
Chicago
04.2020 - 09.2021
- Collaborate with claims department to: Audit check-run, price correctly pending claims, identify authorization issues/trends, and research for potential configuration related work process changes.
- Assist various business units to: Research, document, track, and resolve issues to ensure prompt and accurate claims adjudication as well as assess moving forward with recovery.
- Lead meetings with various departments to assign claim project priorities; and monitor daily in-step processes to ensure projects stay on track.
- Support business initiatives through data analysis, identifying barriers and testing of new systems by users.
- Perform detailed analysis on assigned projects, recommend business solutions and assist with implementation.
- Identify and analyze user requirements, procedures, and problems to improve existing processes.
- Provided training for new hires.
- Prepared policy and procedure manuals and course materials.
- Implemented shadow days for new hires to shadow their teammates for better understanding of their new role.
- Worked in the worker’s compensation department and processed disability claims as needed.
APPEALS & GRIEVANCE SPECIALIST
BENEFIT ADMINISTRATIVE SYSTEMS
Homewood
07.2019 - 01.2020
- Gathered all pertinent and relevant information from the member and/or provider regarding the appeals/grievance; determined the appropriate resolution of the appeals/grievance per standard policies and procedures; ensured that all internal processes are completed to resolve the issue; and notified the appropriate parties of the resolution.
- Conducted non-biased, accurate, timely and comprehensive investigation of all the facts related to the appeals/grievance.
- Documented all action taken on behalf of the member or provider to resolve the appeals/grievance.
CLAIMS ADJUDICATOR III- Remote
EVOLENT HEALTHCARE
Chicago
10.2016 - 06.2019
- Reviewed and finalized entry-level claims.
- Researched CMS1500 claim edits to determine appropriate benefit application utilizing established criteria, applied physician contract pricing as needed for entry-level claims.
- Responsible for adjudicating claims to maintain/comply with Service Level Agreements.
- Determined accurate payment criteria for clearing pending claims based on defined Policy and Procedures.
- Worked high volume of repetitive claims.
- Identified claim(s) with inaccurate data or claims that require review by appropriate team members.
- Maintained productivity goals, quality standards and aging timeframes.
Grievance & Appeals specialist
Molina Healthcare
Oakbrook
01.2016 - 10.2016
- Collected, organized, and tracked information to facilitate and expedite processing of appeals received from various sources.
- Researched, investigated, and resolved administrative aspects of appeals in compliance with corporate and governing regulations.
- Prepared case files on member and provider appeals for internal or external review.
- Participated in all aspects of the grievance/appeals process, specifically intake, triage, coordination and documentation of all grievances, complaints, and appeals.
CARE REVIEW PROCESSOR
MOLINA HEALTHCARE
OAKBROOK
07.2015 - 01.2016
- Checked eligibility and verified benefits, determined provider contracting status via CPL (Certified Provider Listing), determined diagnosis and assigned billing codes (ICD-10 and/or CPT/HCPC codes) and obtained missing/additional information as needed.
- Responded to requests for authorization of services submitted to CAM (Care Access and Monitoring) team via phone, fax and mail according to Molina operational timeframes.
- Provided one-on-one training to new and current staff on processing authorization requests for Molina members that required hospitalization and/or utilization reviews for healthcare services.
- Met and exceeded department productivity standards and quality audit scores by 100%.
Administrative assistant
Comcast Corporation
Tinley Park
09.2007 - 07.2015
- Provided administrative support to senior management and staff in an extremely fast paced environment.
- Coordinated multiple projects; orchestrated meetings, researched agenda items, analyzed data, and compiled reports.
- Maintained necessary office supplies and ensured various equipment was properly configured, installed, and maintained.
- Worked with little supervision/guidance.
- Accountable for individual results and impact on team.
- Represented the XL Center as initial contact for prospective clients and the general public both on the phone and in person.
- Assisted guests with event information and/or routed necessary calls to appropriate personnel.
- Worked closely with Human Resources with assisting with training new hires.
- Prepared training manuals along with provided new hires with updated policies and procedures.
Collections Agent
L.G.B. & S. Law Firm
Chicago
07.2006 - 09.2007
- Utilized various skip tracing techniques and collection strategies (often self-designed) to locate the right party for negotiation of payment arrangements on high collectable or valued accounts.
- The negotiation process often required reviewing the account information in database, and/or asking probing questions of the debtor to better understand potential objections to payment.
- Assisted debtor in identifying payment options to use (credit cards, direct checks, etc.) in order to overcome stalls and objections to paying debt.
- Negotiated settlements outside of normal guidelines, authorized credit bureaus deletions, negotiated special extended payment arrangements, removed accounts out of treatment (close accounts within certain guidelines).
- Advised management regarding collection strategy effectiveness for various portfolios, helped resolve higher level disputes and handled escalated calls from level I and II collectors.
Education
7020- Insurance Adjuster- All Lines Licensure -
Bachelor of Science - Healthcare Management
Colorado Tech University
Colorado Springs, Co 08.2016 - 06.2019
Skills
- Originality and Creativity
- Relationship Building
- Attention to Detail
- Work Planning and Prioritization
- Customer Service
- Effective Communication
- Problem-Solving
- Adaptability
- Teamwork and Collaboration
- Dependability and Cooperation
Timeline
Claim Adjuster
CNA INSURANCE
09.2022 - Current
CLIENT SERVICES LIAISON-OUT OF NETWORK SERVICES
MULTIPLAN
09.2021 - 09.2022
CLAIMS BUSINESS ANALYST
CENTENE HEALTHCARE CORP.
04.2020 - 09.2021
APPEALS & GRIEVANCE SPECIALIST
BENEFIT ADMINISTRATIVE SYSTEMS
07.2019 - 01.2020
CLAIMS ADJUDICATOR III- Remote
EVOLENT HEALTHCARE
10.2016 - 06.2019
Bachelor of Science - Healthcare Management
Colorado Tech University
08.2016 - 06.2019
Grievance & Appeals specialist
Molina Healthcare
01.2016 - 10.2016
CARE REVIEW PROCESSOR
MOLINA HEALTHCARE
07.2015 - 01.2016
Administrative assistant
Comcast Corporation
09.2007 - 07.2015
Collections Agent
L.G.B. & S. Law Firm
07.2006 - 09.2007