Jennifer Hernandez
Santa Clarita,CA
Summary
Claims Examiner with Aims Insurance Services, skilled in claims assessment and customer service. Proven ability to negotiate settlements and resolve complex cases efficiently. Recognized for meticulous attention to detail and strong analytical thinking, consistently delivering accurate reports and enhancing claims resolution processes. Committed to maintaining compliance and fostering positive stakeholder relationships.
Overview
11
11
years of professional experience
Work History
Claims Examiner
Aims Insurance Services
Santa Clarita, CA
03.2022 - Current
- Assessed claim accuracy according to company policies and procedures.
- Verified claimant identity and reviewed information for completeness.
- Ensured compliance with applicable state laws, regulations and standards of practice.
- Prepared various reports documenting findings and recommendations regarding claims resolution.
- Investigated customer inquiries, identified issues and provided solutions.
- Communicated with claimants, attorneys and other parties involved in the process.
- Attended continuing education courses to stay abreast of best practices in the field.
- Analyzed data from medical records, police reports, or other sources to evaluate claim validity.
- Negotiated settlements with claimants as appropriate within established guidelines.
- Maintained detailed records of all activities related to each claim file.
- Developed strategies for processing complex claims quickly and accurately.
- Documented all information regarding claim status in the database system.
- Analyzed information gathered by investigations and reported findings and recommendations.
- Input claim information and payments into company database.
- Maintained accurate records of all claim activities including correspondence, reports, investigations, settlements.
- Prepared detailed reports on claim findings including all pertinent information such as injury description, cause of accident, employer responsibility, and liability.
- Provided customer service by responding promptly to inquiries from claimants, employers, attorneys and other stakeholders.
- Determined liability, compensability, and benefits due on each claim.
- Delivered exceptional customer service to clients by communicating information and actively listening to concerns.
Future Medical Examiner
Aims Insurance Services
Santa Clarita, CA
02.2021 - 03.2022
- Maintained accurate records of all claim activities including correspondence, reports, investigations, settlements.
- Negotiated settlements between claimants and employers or insurers when appropriate.
- Processed benefit payments in accordance with applicable laws and regulations.
- Prepared detailed reports on claim findings including all pertinent information such as injury description, cause of accident, employer responsibility, and liability.
- Provided customer service by responding promptly to inquiries from claimants, employers, attorneys and other stakeholders.
- Developed strategies to resolve complex cases within established timeframes.
Claims Assistant
Aims Insurance Services
Santa Clarita, CA
07.2020 - 01.2021
- Processed payments made by insurance companies according to established protocols.
- Assisted with the preparation of claim forms and related documents for processing.
- Ensured proper coding was used when entering data into system databases.
- Answered incoming calls from claimants, employers, and healthcare providers to provide information about workers' compensation claims.
- Tracked deadlines associated with filing appeals or completing paperwork for new claims and appeals.
- Updated claim notes as needed throughout the life cycle of a case file.
- Communicated effectively with supervisors regarding any issues that arose during the course of handling a case file.
- Handled sensitive information in accordance with company policy and HIPAA regulations.
- Provided customer service to claimants, employers, insurance companies, attorneys. regarding their inquiries or requests for assistance.
- Gathered medical records and other documentation to support claim decisions.
- Checked documentation for appropriate coding, catching errors and making revisions.
- Retained strong medical terminology understanding in effort to better comprehend procedures.
Medical Biller
Synapse Medical Group
Sherman Oaks, CA
03.2014 - 06.2020
- Maintained accurate records of all billing activity in accordance with departmental standards.
- Performed follow up activities on unpaid claims with insurance companies or other third party payers by phone or written correspondence.
- Performed daily reconciliation of accounts receivable with payment postings on the computer system.
- Reviewed patient insurance information to ensure accuracy and completeness of claims submission.
- Verified medical codes for diagnosis, treatments, procedures and supplies using ICD-10 coding system.
- Submitted electronic claims to various insurance carriers.
- Maintained accurate patient data in electronic health records system.
- Ensured compliance with HIPAA guidelines when handling confidential patient information.
- Answered incoming calls regarding billing inquiries from patients and and or providers in a professional manner.
- Assisted with collection efforts as needed including contacting patients via phone, mail or email for collection of past due balances due to insurance denials or patient responsibility amounts owed.
- Researched discrepancies between billed charges and payments received from insurance companies or other third party payers.
- Compiled and processed data for billing purposes utilizing billing software programs.
- Completed and submitted appeals for denied claims.
- Reviewed account information to confirm patient and insurance information is accurate and complete.
- Contacted insurance providers to verify insurance information and obtain billing authorization.
- Applied HIPAA privacy and security regulations while handling patient information.
- Submitted appeals using provider portals and phone communication.
- Input details into accounts and tracked payments.
- Collected, posted and managed patient account payments.
Education
High School Diploma -
Manual Arts High School
Los Angeles, CA09-2009
Skills
- Claims assessment
- Customer service
- Attention to detail
- Problem solving
- Communication skills
- Time management
- Critical thinking
- Workload prioritization
- Goal setting
- Claims resolution
- Organizational skills
- Claims
- Evidence collection
- Self motivation
- Analytical thinking
- Multitasking capacity
Accomplishments
- Rising Star Ribbons received throughout my employment with AIMS.
Languages
English
Professional
Spanish
Professional
Timeline
Claims Examiner
Aims Insurance Services
03.2022 - Current
Future Medical Examiner
Aims Insurance Services
02.2021 - 03.2022
Claims Assistant
Aims Insurance Services
07.2020 - 01.2021
Medical Biller
Synapse Medical Group
03.2014 - 06.2020
High School Diploma -
Manual Arts High School
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