Jeffrey Polonchak
Harrisburg,PA
Summary
Experienced Senior Claims Examiner with a proven track record in claims evaluation, regulatory compliance, and training. Skilled in policy analysis and medical record review, driving efficient claims processing and enhanced team performance.
Overview
19
19
years of professional experience
Work History
Senior Claims Examiner
Capital BlueCross
Harrisburg, Pennsylvania
10.2006 - Current
- Evaluated complex insurance claims for accuracy and compliance with regulations.
- Collaborated with healthcare providers to gather necessary documentation and information.
- Assisted in training new claims examiners on procedures and best practices.
- Reviewed policies to determine coverage eligibility and claim validity.
- Utilized claims processing software to manage and track claim statuses efficiently.
- Identified trends in claim submissions to recommend process improvements and efficiencies.
- Participated in meetings with senior management personnel to discuss policy changes related to claims adjudication.
- Kept team operating well through timely contact with insured and claimants, professional support and thorough work.
- Reviewed and evaluated complex insurance claims to determine coverage, liability, and damages.
- Adjusted reserves to maintain consistency with established operational and risk guidelines.
- Analyzed medical records to identify discrepancies between the claim and treatment history.
- Advised junior staff members on technical aspects of adjudicating difficult cases.
- Approved payment requests based on established guidelines and criteria.
- Resolved escalated complaints from clients regarding denied or delayed payments.
- Maintained detailed records of all activities associated with each case file.
- Provided training sessions for new employees on proper procedures for handling claims.
Education
High School Diploma -
Shippensburg University of Pennsylvania
Shippensburg, PASkills
- Claims evaluation
- Policy analysis
- Claims processing software
- Medical record analysis
- Training and development
- Regulatory compliance
Timeline
Senior Claims Examiner
Capital BlueCross
10.2006 - Current
High School Diploma -
Shippensburg University of Pennsylvania