Chinere Industrious
Orlando,FL
Summary
Medical claims professional prepared for role with comprehensive experience in claim assessment and resolution. Known for meticulous attention to detail and proven ability to streamline claim processing. Recognized for fostering team collaboration and adapting to dynamic environments. Expertise includes medical coding, policy interpretation, and customer service.
Overview
21
21
years of professional experience
Work History
Medical Claims Adjuster
Progressive Insurance
05.2020 - Current
- Investigating claims thoroughly to ensure they meet all requirements, including legal standards and company policies
- Negotiating with insurance companies over coverage issues, claim denials, or payment amounts
- Researching medical terminology in order to understand medical procedures or diagnoses
- Communicating with patients and their families regarding claim status, treatment plans, or any other issues relevant to their cases
- Maintaining detailed records of all claims activities, including information about the claimant, insurance company representatives, and other parties involved in the claim process
- Reviewing medical bills and records to determine if they are correct and complete
- Coordinating with medical providers and other third parties to collect information needed for claims processing
- Reviewing medical claims for accuracy and completeness, and determining if they are covered by insurance policies or if additional information is needed before making a determination
- Determining coverage eligibility of claims based on the terms of the insurance policy
- Analyzed policy details along with supporting documents provided by healthcare providers to make informed decisions on claims approvals or denials.
- Resolved complex claims issues for expedited processing and resolution.
- Reduced claim processing time by streamlining medical claims adjudication processes.
- Managed high volume caseloads, prioritizing urgent and sensitive cases for immediate attention.
- Provided exceptional customer service to both internal and external stakeholders during the entire claim lifecycle process.
- Developed customized reports for management review, highlighting key trends and areas of improvement in claims handling process.
- Managed large volume of medical claims on daily basis.
- Reviewed provider coding information to report services and verify correctness.
- 6-20 adjuster license
- Responded to correspondence from insurance companies.
- Followed up on denied claims to verify timely patient payment and resolution.
Case Manager
ReedGroup
08.2014 - 04.2020
- Uses experience and knowledge to manage both disability and leave claims
- Provides total claim management
- Obtains and reviews updated medical evidence for claim decisions
- Composes and sends communications to employers and employees within appropriate time frames
- Delivers excellent customer service to client companies and claimants through written correspondence and inbound/outbound calls
- Provides support for all assigned accounts by setting time frames to meet quality assurance and client performance guarantees
- Provides support to Intake/Customer Service team as needed in the Call Center
- Knowledge of the Family Medical Leave Act
- Knowledge of MDA Guidelines
- Knowledge of medical terminology ICD9/ ICD10 codes
- Ensures compliance and proper documentation in regard to all applicable laws, regulations, and plans, including HIPAA, FMLA, and all individual State Leave Acts, Military, and Company Sponsored Leave Programs
- Follows the designated escalation process to the Nurse Case Manager as applicable
- Communicate with claimants, planholders, and physicians as needed for information needed for initial and ongoing leave management
- Proactively communicates with client companies to review case management and claims experience
- Consult with Risk Management area to assess functionality and return to work potential by utilizing available resources
- Partnering with Short Term Disability on large group claims for early intervention when claims are identified as having potential to transition to Long Term Disability in order to reduce potential risk exposure
- Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
- Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
- Monitored ongoing cases closely, adjusting case management strategies as needed based on evolving circumstances or new information.
- Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
- Enhanced communication between clients and providers through consistent follow-ups and progress updates.
- Advocated for client rights when interacting with external agencies or institutions, ensuring fair treatment at all times.
- Contributed to team discussions and case conferences actively, sharing insights and expertise with colleagues to optimize client support strategies.
- Achieved positive client outcomes by developing and implementing comprehensive case management plans.
Office Administrator/Accounts payable
The-Ritz Carlton
02.2004 - 08.2014
- Functioned as back-up to the Admissions Director, Medical Records Director and Business Office Coordinator
- Perform general office administrative functions and processing of payroll
- Review/audit all transaction and activities for the recreation department
- Data entry
- Reconcile and balance daily Lady Lynsey and Aquatic Center office receipts
- Issue/manage daily hotel activities sheet
- Ensure our master training manual is updated with all corporate standards
- Ensure all vendors of the resort coil/contracts are up to date
- Support Office Manager by ensuring adequate office/operations coverage and company policy standards
- Directed incoming calls; initiated new vendor application process
- Reconcile and pay corporate credit cards
- Manage monthly closing of AP records
- Supervised all aspects of daily operations for up to15 employees
- Generated invoices
- Paid all vendors using PeopleSoft system
- Assigning correct GL and cost codes to transactions
- Trained all new hires on4 my HR and audited staff
- Weekly inventory control for the Engineering Department
- Reconcile and balance gas/diesel delivery
- Call Center Experience
- Coordinated communications, financial processing, registration, recordkeeping, and other administrative functions.
- Maintained electronic and paper filing systems for easy retrieval of information.
- Answered multi-line phone system, routing calls, delivering messages to staff and greeting visitors.
- Demonstrated exceptional multitasking abilities while juggling diverse responsibilities, including reception duties and ad-hoc administrative tasks.
- Increased customer satisfaction through professional handling of inquiries and prompt resolution of issues.
- Contributed to a positive work environment by fostering strong working relationships among colleagues.
- Reduced administrative errors by diligently proofreading office documents and maintaining accurate records.
- Reconciled account files and produced monthly reports.
- Maximized office space utilization by maintaining a clean, organized work environment that encouraged productivity and efficiency.
- Expedited invoice processing by accurately reviewing vendor submissions, reconciling accounts payable discrepancies, and conducting timely payments.
- Safeguarded company information by maintaining strict confidentiality protocols and ensuring secure document storage practices.
- Boosted productivity by prioritizing tasks, managing schedules, and coordinating meetings for staff members.
- Facilitated smooth operations by maintaining updated inventory records, anticipating supply needs, and placing timely orders for essential materials.
- Aided in employee onboarding through training new hires on office procedures, software applications, and company policies.
Education
Medical coding/billing program -
Florida Technical College
Orlando, FL01.2017
Diploma -
Ivanna Eudora Kean High School
St.Thomas, V.I01.1999
Skills
- Customer service
- Highly adaptable
- Strong work ethic
- Effective problem solving
- Proactive attitude
- Excellent multitasking
- Team player mentality
- Administrative support
- Detail-oriented approach
- Policy interpretation
- Claims investigation and research
- Procedure implementation
- Claims analysis
- Claims auditing
- Planning and organization
- Claims processing
- Performance monitoring
Timeline
Medical Claims Adjuster
Progressive Insurance
05.2020 - Current
Case Manager
ReedGroup
08.2014 - 04.2020
Office Administrator/Accounts payable
The-Ritz Carlton
02.2004 - 08.2014
Medical coding/billing program -
Florida Technical College
Diploma -
Ivanna Eudora Kean High School
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