Karina Felix
Orlando,FL
Summary
Dynamic Claims Specialist with over 8 years of experience in insurance claims operations, medical billing, and benefits investigation. Demonstrates a strong ability to evaluate complex documentation and identify discrepancies while ensuring compliance with regulatory and organizational standards. Proven track record in managing high-volume caseloads, enhancing claim accuracy, and effectively resolving intricate issues through collaboration with providers, payers, and internal stakeholders. Currently pursuing a Bachelor of Science in Healthcare Risk Management (Expected 2027) to deepen expertise in risk management, compliance, and claims strategy. Dedicated team player committed to treating clients fairly and thriving in fast-paced, deadline-driven environments.
Overview
18
18
years of professional experience
Work History
Claims Specialist / Medical Billing Analyst
Progressive Insurance
03.2016 - 03.2024
- Managed a high-volume caseload of complex insurance claims, consistently meeting productivity and accuracy expectations.
- Conducted in-depth review of medical records, police reports, and claim documentation to determine coverage, liability, and appropriate resolution.
- Analyzed detailed medical bills and identified coding errors, duplicate charges, and inconsistencies, working directly with providers and coders to resolve discrepancies.
- Performed comprehensive claims audits, strengthening claim quality and reducing downstream rework and payment errors.
- Led benefits investigations with third-party payers, accelerating reimbursement timelines and reducing outstanding balances.
- Maintained strict adherence to regulatory requirements, internal policies, and compliance standards when handling sensitive claim information.
- Partnered closely with underwriting, risk management, and internal teams to support informed and defensible claim decisions.
- Built strong professional relationships with providers, adjusters, and external stakeholders, improving communication and resolution outcomes.
- Recognized for maintaining organized documentation and thorough case notes, supporting audit readiness and legal defensibility.
- Demonstrated strong judgment when handling escalated or complex claims requiring detailed analysis.
Customer Service Billing Agent
Walgreens Customer Care Center
12.2011 - 12.2013
- Delivered high-quality customer support for billing and account inquiries across multiple channels (phone, email, chat).
- Resolved complex and escalated billing concerns through critical thinking and clear communication.
- Accurately documented all customer interactions to support compliance, quality standards, and process improvement.
- Consistently maintained professionalism while managing sensitive or frustrated customer interactions.
- Collaborated with internal departments to drive faster issue resolution and improve customer experience.
Customer Service / Sales / Technical Support
CenturyLink
12.2006 - 12.2011
- Managed continuous inbound customer interactions related to billing, accounts, and service concerns.
- Clearly explained policies, pricing, and service options, improving customer understanding and trust.
- Negotiated payment arrangements while maintaining strong customer relationships.
- Identified opportunities to recommend appropriate services based on customer needs.
- Troubleshot technical service issues efficiently, ensuring timely resolution.
- Maintained accurate documentation for quality assurance and compliance purposes.
Patient Care Advocate
Nations Health
12.2005 - 12.2007
- Assisted Medicare beneficiaries with Medicare Part D enrollment, benefits, and claims-related issues.
- Processed claims while ensuring strict compliance with HIPAA and privacy regulations.
- Educated members on prescription drug options, pharmacy usage, and cost-saving opportunities.
- Resolved sensitive billing and service issues with empathy, professionalism, and accuracy.
- Escalated complex grievances appropriately to ensure full investigation and resolution.
Education
Bachelor of Science - Healthcare Risk Management
Daytona State College
Daytona Beach, FL03-2027
Associate in Science (A.S.) - Health Care Administration
Anthem Career College
Orlando, FL06-2014
Skills
- Insurance Claims Processing & Adjudication
- Claims Investigation & Resolution
- Coverage Determination & Documentation Review
- Medical Records Analysis
- Medical Billing & CPT Coding Review
- Benefits Verification & Coordination
- Claims Auditing & Quality Assurance
- Regulatory Compliance (HIPAA, industry guidelines)
- Risk Assessment & Error Detection
- Fraud Awareness & Discrepancy Identification
- Process Improvement
- Case Prioritization & Time Management
- Stakeholder Communication (Providers, Insureds, Payers)
- Conflict Resolution & Negotiation
- Cross-Functional Collaboration
Timeline
Claims Specialist / Medical Billing Analyst
Progressive Insurance
03.2016 - 03.2024
Customer Service Billing Agent
Walgreens Customer Care Center
12.2011 - 12.2013
Customer Service / Sales / Technical Support
CenturyLink
12.2006 - 12.2011
Patient Care Advocate
Nations Health
12.2005 - 12.2007
Bachelor of Science - Healthcare Risk Management
Daytona State College
Associate in Science (A.S.) - Health Care Administration
Anthem Career College