Joe Jones
Summary
Experienced in conducting thorough investigations into suspicious claims, identifying fraudulent activities while ensuring compliance with industry regulations. Demonstrated ability to collaborate with law enforcement and legal teams, facilitating successful resolutions of complex claims disputes. Proven track record of managing multiple investigations simultaneously while maintaining detailed case logs and meeting strict deadlines. Skilled in navigating complex insurance claims and SIU investigations. Efficient in subrogation and underwritten referrals.
Overview
12
12
years of professional experience
1
1
year of post-secondary education
1
1
Certification
Work History
SIU Investigator
Progressive Insurance
Dallas, TX
02.2023 - Current
- Conducted thorough investigations into suspicious claims, leading to the identification of fraudulent activities and ensuring compliance with industry regulations.
- Collaborated with law enforcement and legal teams to gather evidence and facilitate successful resolutions of complex claims disputes.
- Engaged in ongoing professional development to stay current with industry trends, regulations, and emerging fraud schemes, enhancing overall investigative effectiveness.
- Performed background checks on individuals under investigation.
- Presented investigative findings in both written and oral form to appropriate personnel.
- Reviewed case files, documents, evidence, and other materials related to investigations.
- Conducted interviews with witnesses and suspects to gain information relevant to investigations.
- Developed strategies for conducting investigations into alleged violations of regulations or laws.
- Identified potential areas of investigation through analysis of data collected during initial stages of the investigation.
- Managed multiple ongoing investigations simultaneously while meeting strict deadlines.
- Maintained contact with local law enforcement agencies regarding cases being investigated.
- Interviewed subjects, targets and witnesses for information verification and corroboration.
- Maintained detailed case log of all cases assigned to monitor progress and completion.
- Eliminated process discrepancies by accurately investigating organized crime, homicide, fraud and other major crime cases while preparing, submitting, and aiding district attorney prosecution cases.
Auto Claims Adjuster
American Family Insurance
Dallas, TX
09.2020 - 11.2022
- Evaluated insurance claims by meticulously reviewing documentation, resulting in accurate determinations of liability and coverage.
- Collaborated with clients and service providers to gather information, ensuring timely resolution of claims and enhanced customer satisfaction.
- Analyzed loss reports and assessed damages to establish claim validity, leading to more efficient claims processing and reduced turnaround times.
- Implemented process improvements in claims handling, streamlining workflows and contributing to a reduction in operational delays.
- Developed and maintained strong relationships with clients, promoting trust and ensuring clear communication throughout the claims process.
- Determined liability based on facts gathered from investigations.
- Managed multiple cases simultaneously while meeting established deadlines.
- Interviewed claimants, witnesses, police officers, medical professionals and other parties involved in the claim.
- Processed payments according to terms outlined in policy contracts.
- Reviewed previous claims for possible fraud or misrepresentation of facts.
- Researched and verified insurance policy coverage.
- Analyzed policy language to ensure compliance with state regulations and company policies.
- Established relationships with attorneys, medical providers and other service providers who assist in the resolution of claims.
- Evaluated repair estimates for reasonableness and accuracy prior to authorizing repairs.
- Prepared detailed reports summarizing all aspects of the claims process.
- Evaluated extent of damage and documented findings.
- Assessed damages to vehicles and property resulting from a variety of incidents.
- Collaborated with medical professionals to assess injury claims and determine settlement amounts.
- Utilized claims software and databases for tracking and managing active claims.
- Conducted in-person and remote assessments of vehicle damages for accurate claim valuation.
Medical Claims Representative
United Healthcare
Sugar Land, Texas
03.2016 - 07.2020
- Collaborated with healthcare providers and insurance adjusters to resolve discrepancies, streamlining claims processing and enhancing operational efficiency.
- Utilized claims processing software to track and manage claims, improving turnaround time and maintaining high service quality.
- Educated clients on claims procedures and benefits coverage, enhancing understanding and satisfaction with the claims process.
- Prepared detailed reports on trends in denials, rejections, appeals, collections.
- Processed payments from various insurance companies according to their guidelines.
- Verified coding accuracy on medical bills in accordance with insurance regulations.
- Compiled and submitted claims forms, medical reports, and other supporting documents to insurance companies.
- Assisted customers with inquiries about the status of their claims via telephone or email.
- Maintained detailed records of all activities related to claims processing.
- Investigated and resolved denied or rejected claims quickly and accurately.
- Advised patients regarding billing issues, payment options, and reimbursement procedures.
- Interpreted policy language to determine coverage levels for each claim submitted.
- Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
- Reviewed claims for accuracy before submitting for billing.
- Collaborated with healthcare professionals to ensure compliance with applicable laws and regulations.
- Reviewed patient records to verify insurance coverage and eligibility for services.
Medical Claims Specialist
United Healthcare
Houston, TX
03.2017 - 06.2020
- Assessed coding accuracy, using ICD-10 codes, CPT codes, HCPCS codes, and modifiers.
- Analyzed provider contracts to ensure proper reimbursement levels were achieved.
- Researched medical records to identify additional information needed for processing claims.
- Resolved issues related to denied or underpaid claims in a timely manner.
- Conducted research into complex medical coding issues to ensure proper reimbursement.
- Ensured compliance with applicable federal and state laws governing healthcare payments.
- Provided feedback on coding errors and discrepancies found in submitted claims.
- Reviewed denials, rejections, and underpayments from insurance carriers.
- Processed appeals on rejected or partially paid claims, including filing additional paperwork as needed.
- Submitted and tracked medical claims to insurance companies via electronic or paper methods.
- Identified incorrect charges on invoices by comparing them against contracts and fee schedules.
- Verified patient eligibility for medical claims and determined benefit coverage.
- Responded promptly to customer inquiries regarding claim status updates.
- Adhered to HIPAA regulations while managing confidential patient information.
- Tracked differences between plans to correctly determine eligibility and assess claims against benefits and data entry requirements.
- Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
- Accurately processed large volume of medical claims every shift.
- Sent clinical request and missing information letters to obtain incomplete information.
- Based payment or denials of medical claims upon well-established criteria for claims processing.
- Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
- Examined claims, records and procedures to grant approval of coverage.
- Examined automobile policies with third-party liability, accident benefits, and collision benefits.
- Drafted statements of loss to summarize payments, underlying policy coverages and damages.
Customer Service Representative
Blue Cross Blue Shield of Texas
Houston, TX
10.2013 - 12.2016
- Adjusted bills and refunded money to resolve customers' service or billing complaints.
- Assisted with customer inquiries, complaints, and requests for information regarding insurance policies.
- Provided quotes on various types of insurance policies.
- Advised customers on available coverage options that best fit their individual needs.
- Answered insurance-related questions and discussed product offerings with prospective customers to meet unique needs.
- Greeted customers and provided prompt, courteous service.
- Responded to queries, solved, or referred problems and followed up with clients to increase satisfaction.
- Conducted follow-up calls to ensure satisfactory resolution of customer issues.
- Asked probing questions and offered solutions to resolve customer issues.
- Ensured compliance with company guidelines and regulatory standards when dealing with customers' accounts or policies.
- Facilitated communication between customers and third-party service providers.
- Coordinated with insurance agents and underwriters to facilitate policy adjustments.
- Remained calm and professional in stressful circumstances and effectively diffused tense situations.
- Answered customer inquiries and provided accurate information regarding products and services.
- Answered incoming calls from customers and provided assistance with product inquiries, billing questions, and other customer service related issues.
- Maintained high levels of professionalism while interacting with customers via phone or email.
- Updated customer accounts, addresses and contact information within call management databases.
Education
High School Diploma -
John Foster Dulles Sr. High School
Sugar Land, TxAssociate of Applied Science - Allied Health
Fortis College
Houston, Tx 08.2012 - 01.2014
Skills
- Customer service, Administrative support, Problem solving, CRM, Medical terminology, Technical support, ICD-9 coding, HIPAA, Policy interpretation, Claims investigation, Damage assessment, Claims processing, Insurance policy, Fraud detection, Insurance regulations, Settlement negotiations, Liability determination, Xactimate, Claims X, Data analysis, Negotiation skills, Team collaboration, Risk assessment, Regulatory compliance, Conflict resolution, Financial analysis, Quality assurance, Project management, Client relations, Workflow optimization, Claims auditing, Insurance underwriting, Compliance monitoring, Risk management, Subrogation
- Fraud detection
- Liability determination
- Regulatory compliance
- Multi-case handling
- Policy interpretation
- Risk assessment
EMPLOYMENT HISTORY
01-2024
Certification
Texas All Lines Property Adjuster License
Timeline
SIU Investigator
Progressive Insurance
02.2023 - Current
Auto Claims Adjuster
American Family Insurance
09.2020 - 11.2022
Medical Claims Specialist
United Healthcare
03.2017 - 06.2020
Medical Claims Representative
United Healthcare
03.2016 - 07.2020
Customer Service Representative
Blue Cross Blue Shield of Texas
10.2013 - 12.2016
Associate of Applied Science - Allied Health
Fortis College
08.2012 - 01.2014
High School Diploma -
John Foster Dulles Sr. High School