Janesse Nieves

• Leveraged analytical thinking when evaluating policy interpretations in order to accurately assess liability outcomes.
• Collaborated with adjusters and underwriters to verify coverage details, ensuring accurate claim settlements.
• Proactively participated in ongoing professional development to maintain up-to-date knowledge of industry trends, resulting in improved performance and higher levels of client satisfaction.
• Improved claim processing efficiency by meticulously reviewing and analyzing insurance claims.
• Enhanced customer satisfaction by promptly addressing client concerns and resolving disputes professionally.
• Demonstrated advanced technical skills in navigating internal systems for efficient record-keeping and data management related to claim files.
• Managed high volume of claims efficiently by prioritizing tasks in fast-paced environment.
• Expedited claim resolutions by effectively negotiating with clients, legal representatives, and other stakeholders.
• Handled multi-line insurance claims proficiently, displaying adaptability across various product types.
• Established rapport with clients through empathetic communication skills while managing sensitive information during claim evaluation processes.
• Maintained comprehensive knowledge of insurance products and regulations to provide informed guidance during claims process.
• Reviewed applications and supporting documents to verify claims eligibility and accuracy.
• Managed workload and priorities to meet claims processing meet deadlines.
• Complied with regulations and guidelines related to claims processing to maintain quality and adherence to standards.
• Followed up with customers on unresolved issues.
• Responded to customer inquiries, providing detailed explanations of insurance policies and claims processes.
• Utilized excellent analytical and problem-solving skills to quickly and accurately assess insurance claims.
• Managed same day contact to policyholders, claim reporters, brokers, producer and claimants including other Insurance carriers.
• Managed claims from beginning to end within 15 days of reporting. Completing handling less than 15 days at least 63% and within 16-30 days at max 37%
• Reduced fraudulent claims through thorough investigations and strict adherence to company policies.

• Collaborated with claims department and industry anti-fraud organizations to resolve claims.
• Reported policy changes and company conditions affecting customer satisfaction.
• Analyzed information gathered by investigations to report findings and recommendations.
• Followed up with customers on unresolved issues.
• Modeled exceptional customer service skills and appropriate diagnostic sales techniques to team members.
• Evaluated accuracy and quality of data entered into agency management system.
• Interviewed agents and claimants to correct errors or omissions and investigate questionable claims.
• Made contact with insurance carriers to discuss policies and individual patient benefits.
• Generated, posted and attached information to claim files.
• Prepared insurance claim forms or related documents and reviewed for completeness.
• Reviewed outstanding requests and redirected workloads to complete projects on time.

• Performed in lead capacity for technical and administrative activities under Physical Medicine and Rehabilitation and Orthopedic Surgery Registration Department.
• Assisted Supervisor in providing day-to-day coordination of call center activity. Assisting with training staff and served as resource to Staff relations in complex situations decreasing requests for escalated case handling
• Received inbound contacts (calls, emails, faxes, etc.) from patients and physicians requesting services within JHMI.
  
• Established methods for complex appointment scheduling linking consults, procedures and ancillary services required for specialty and multiple sub-specialties maintaining patient demographic and insurance pre-registration information in multiple scheduling systems (Meditech, IDX, OCIS, MOSAIQ or EPIC).
  Referral tracking and handling of MediCal records.
• Provide patients with information on physicians, directions to locations and educational materials. Answer patients or physicians questions.
  

Maintaining 90% club average in Quality Assurance month- to -month and contributing to quota adherences weekly above 90% on all standardized metrics.

• Provide excellent customer service to customers by answering inquiries, finding correct solutions. Responsible for all customer inquiries and questions.
• Follow up to customer inquiries by taking specific action in timely manners, gathering as much information and determining right course of action with Policy Holders.
• Problem solve to help customers resolve issues on first call implementing critical thinking and reconciliation. Enter data from customers into various software programs including but not limited to, Lotus Notes, Omni software. Additional use of EVS.
• Established rapport and appropriately communicated with upset customers to resolve their inquiries, maintaining composer and controlling work flow using various communication skills including empathy, balanced-tone of voice and clear explanation of Policy Coverages.
• Thriving Team Player accustomed within fast-paced, high-energy, change-oriented environments.
• Increased retention efforts when required. Time-management of High Call Volumes upward of 200 calls per day, monitored by Quality Assurance. Averaging 90% month-to-month in quality with minimal errors and crossed trained in MediCal for California.