Joyce M. Rodriguez
Pittsburgh,PA
Summary
Detail-oriented Claims Investigator with a strong track record in optimizing claims processes and driving organizational efficiencies. Proven expertise in data collection and analysis, contributing significantly to overall operational success.
Overview
12
12
years of professional experience
Work History
Adjuster II
UPMC
Pittsburgh, USA
12.2021 - Current
- Ensured legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations
- Resolved medical claims by approving or denying submitted documentation, calculating benefits due, initiating payment, or composing denial letter
- Consistently document medical claims actions by completing forms, reports, logs, and records
Claims Processor
UnitedHealth Group
Pittsburgh, USA
03.2021 - 12.2021
- Reviewed and researched incoming healthcare claims by navigating multiple computers systems and platforms
- Actively followed up and collected information on all electronic claims, including resolution of any billing errors assigned following established procedures
- Consistently meet performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendance
Group Claims Senior Representative – Short Term Disability
Cigna now known as NY Life GBS
Pittsburgh, USA
11.2020 - 03.2021
- Communicates with claimants, employers, and various medical professionals to gather information regarding the application for, payment of, and ongoing management of short-term disability benefits
- Networks with both customers and healthcare staff to medically manage claims from initial medical requests to reviewing and evaluating ongoing medical information
- Determines customer eligibility by reviewing contractual language and medical documentation, interprets information and makes decisions based on facts presented
911 Telecommunications Officer
Allegheny County Emergency Services
Moon, USA
04.2020 - 06.2020
- Assisted first responders by collecting caller information, reported and input emergency information into the computer aided dispatching system (C.A.D)
- Responsible for maintaining high levels of confidential and sensitive data
- Assisted callers by providing basic life support measures via phone
Claims Adjuster
UnitedHealth Group
Pittsburgh, USA
06.2013 - 04.2020
- Investigated complex claims-processing issues by researching provider’s contracts and member’s schedules of benefits to ensure proper benefits paid
- Assisted with creating systems and training representatives to help increase adjustment productivity
- Evaluated claims to guarantee proper procedures followed by determining benefits, reviewing medical records and compiling information to resolve issues, and follow up to confirm first call resolution
Education
GED -
NY State Department of Education
New York, NY04-1997
Skills
- Policy interpretation
- Claims investigation
- Insurance regulations
- Policy investigations
- Workers' compensation claims
- Claims review
- Medical terminology
- Accuracy and precision
- Claims adjustment
- Adaptability and flexibility
References
References are available on request.
References
References available upon request.
Timeline
Adjuster II
UPMC
12.2021 - Current
Claims Processor
UnitedHealth Group
03.2021 - 12.2021
Group Claims Senior Representative – Short Term Disability
Cigna now known as NY Life GBS
11.2020 - 03.2021
911 Telecommunications Officer
Allegheny County Emergency Services
04.2020 - 06.2020
Claims Adjuster
UnitedHealth Group
06.2013 - 04.2020
GED -
NY State Department of Education