Karlya Heartfield
Middle River,MD
Summary
Detail-oriented healthcare claims professional with over 5 years of experience in supporting claims operations, provider services, and healthcare administration within high-volume, metrics-driven environments. Expertise in reviewing, investigating, and resolving complex claims while ensuring exceptional accuracy and compliance with CMS and HIPAA regulations. Proven track record of validating claim information, identifying discrepancies, and documenting activities within claims systems to facilitate timely resolutions. Recognized for strong analytical skills and a member-first approach that fosters positive healthcare experiences while consistently meeting quality and performance standards.
Overview
5
5
years of professional experience
1
1
Certification
Work History
Independent Contractor – Customer Support
LiveOps
Scottsdale, AZ
02.2026 - Current
- Delivered exceptional customer service through effective communication and problem resolution.
- Maintained accurate records of customer interactions using CRM software.
- Review and investigate healthcare claims inquiries while navigating multiple claims systems to validate claim status and supporting documentation.
- Analyze claims-related information involving eligibility, benefits, prior authorizations, appeals, and claim outcomes in accordance with CMS guidelines.
- Reviewed claim information involving CPT, HCPCS, and ICD-10 diagnosis and procedure codes to support accurate claim handling and issue resolution.
- Identify discrepancies, missing information, and unusual claim scenarios, escalating issues appropriately to ensure accurate resolution.
- Maintain accurate records and detailed documentation of all provider interactions within internal systems.
- Manage high volumes of inbound inquiries while consistently meeting productivity and quality expectations.
- Protect sensitive member and provider information by adhering to HIPAA requirements and privacy standards.
- Work independently in a fully remote environment while maintaining responsiveness, accountability, and consistent performance.
Seasonal Licensed Member Advisor
BroadPath LLC
Tucson, AZ
09.2024 - 01.2026
- Facilitated member onboarding processes, enhancing member engagement and satisfaction.
- Provided expert guidance on product offerings, ensuring alignment with member needs.
- Determined the best way to resolve member inquiries by asking probing questions and making appropriate recommendations based on health insurance product path and program.
- Demonstrated empathy and active listening in each interaction with the caller.
- Documented all interactions within our Customer Relationship Management (CRM) platform with clarity and professionalism.
- Collaborated with other third-party entities, navigators/brokers, and internal departments to assist with callers’ needs.
Licensed Health & Life Agent Telesales
Sutherland Global Remote Healthcare
Pittsford, NY
04.2024 - 09.2024
- Promoted to Licensed Health & Life Insurance Agent.
- Worked directly with leads to help solve benefits challenges with our plans and services.
- Generated sales with company provided leads, personal networking, referrals and cold calls.
- Conducted engaging sales presentations and enrollments at worksites and remote environments.
- Provided excellent customer service and claims support to new and existing policyholders.
Healthcare Provider Support
09.2021 - 04.2024
- Handled and documented an estimated number of 20+ calls daily along with escalated supervisor requested calls.
- Assisted with internal coachings regarding employment development.
- Reviewed claim information involving CPT, HCPCS, and ICD-10 diagnosis and procedure codes to support accurate claim handling and issue resolution.
- Analyzed, investigated, and adjusted claims while following CMS guidelines.
- Educated healthcare providers with understanding claims, prior authorizations, appeal status, eligibility and benefit information in reference to patients health plan.
- Achieved 100 % driven results rated top 3 in Quality Assurance performance.
- Abided by HIPPA rules and regulations while verifying and providing member and provider information.
Education
Associate of Applied Science - Information Technology
Community College of Baltimore County
Baltimore, MD03.2027
High School Diploma -
Edmondson-Westside High School
Baltimore, MD06.2007
Skills
- Customer Service
- Claims processing
- Health Insurance
- Problem Solving
- Critical Thinking
- Medical Terminology
- Data Analysis
- Microsoft Office 365
- Technical Support & Troubleshooting
- Analytical Thinking
- Database Management
- Multitasking Abilities
Certification
- Insurance Producer - Accident and Health or Sickness, Life
- License No: 3003014340
- NPN: 21116920
Timeline
Independent Contractor – Customer Support
LiveOps
02.2026 - Current
Seasonal Licensed Member Advisor
BroadPath LLC
09.2024 - 01.2026
Licensed Health & Life Agent Telesales
Sutherland Global Remote Healthcare
04.2024 - 09.2024
Healthcare Provider Support
09.2021 - 04.2024
Associate of Applied Science - Information Technology
Community College of Baltimore County
High School Diploma -
Edmondson-Westside High School