Keyna Duval
Cocoa,Florida
Summary
Professional claims specialist with strong record in handling and resolving complex claims efficiently. Adept at analyzing data, identifying discrepancies, and providing solutions that drive positive outcomes. Effective team collaborator with focus on achieving results and adapting to evolving requirements. Skilled in negotiation, customer service, and regulatory compliance, consistently ensuring accuracy and fairness.
Overview
17
17
years of professional experience
Work History
Claims Specialist Int
Progressive Insurance
09.2019 - Current
- Reviews and researches the policy contract, regulation, injury causation/mechanism of injury to make coverage decisions
- Understands how to recognize the potential exposure of a claim and adjust reserves accordingly
- May review and interpret policy language upon receipt of a subrogation demand to determine if reimbursement is owed
- Interprets medical records and understands medical terminology regarding injuries
- Reads/conducts research to better understand medical records and establish any correlation to a motor vehicle accident could also research injuries or medical conditions
- Injury causation may involve following up with a provider and/or securing medical records and ultimately recognizing the need for an IME/IMR
- Reviews newly assigned claim files
- Interprets policy and state laws in order to make accurate coverage decisions
- Investigates coverage, liability, fraud, injury causation and subrogation issues
- Identifies all parties' material to the investigation, and determines
- Verifies and resolves Claims Verification Questions, sends underwriting memos, completes liability investigations, recognizes the need for fraud/SIU involvement and opens/refers subrogation as needed
- Develops and executes action plans around coverage, fraud, injury causation and subrogation issues
- Maintains diaries and the completion of accurate and comprehensive file documentation
- Respond with urgency to all communication including phone calls incoming mail and electronic correspondence
- Keep insureds, attorneys and medical providers up to date and honor commitments to follow up for current file status
- Provide excellent service to internal and external customers by clarifying the claims process, setting expectations, providing accurate information about benefits, and anticipating customer needs
- Completes any and all tasks a file may need to bring the file towards resolution
- Minimize interest owed due to late payments by proactively working each issue towards resolution
Medical Claims Rep
Progressive Insurance
05.2018 - 09.2019
- Reviews and researches the policy contract, regulation, injury causation/mechanism of injury to make accurate coverage decisions
- Reads/conducts research to better understand medical records and establish any correlation to a motor vehicle accident
- Identifies, reviews and researches wage loss expenses and documentation for payment consideration (when applicable)
- May review and interpret policy language upon receipt of a subrogation demand to determine if reimbursement is owed
- Reviews medical records and ultimately recognizing the need for an IME/IMR
- Reviews newly assigned claim files
- Completes all tasks a file may need to bring the file towards resolution
- Maintains diaries and the completion of accurate and comprehensive file documentation
Child Protective Investigator Supervisor
Department of Children and Families
08.2013 - 05.2018
- Ensure that daily operations are within legislative authority and in compliance with required federal, state rules and regulations
- Identify improvements and implements adjustments needed to ensure program effectiveness and efficiency
- Supervise, plan and direct workloads, work flows, deadlines, work objectives and time utilization of staff
- Establish and maintain cooperative working relationships with organizations and other agencies involved with investigations such as community-based providers, Children’s Legal Services, law enforcement, medical personnel, schools, and other community/agency resources
- Identifies all parties' material to the investigation
- Independently performs investigative fieldwork to verify information and/or investigative leads
- Utilizes appropriate investigative tools (i.e
- Databases, informational resources and public records) to verify information and/or identify investigative leads
- Develop performance standards and job duty expectations with investigators, review standards and plans for continuous improvement
- Promote career development of investigators by ensuring each individual receives the proper training and serve as facilitator of cross-training efforts on differential investigative skills
- Review casework, assessments and safety plans with investigators, and provide consultation and direction to assure appropriateness, clarity, quality, thoroughness and proper documentation
- Data tracking to include running daily reports to provide summaries, analyzing caseloads and case types as well as case participants to include vulnerable child
- Identify improvements and implements adjustments needed to ensure program effectiveness and efficiency
- Serve as Program Administrator on an as needed basis, facilitating the day to day operations of the facility (in the absence of the program administrator)
- Ensures compliance with applicable statutes, rules, policies, and performance standards
- Analyzes assigned area/unit/individual performance and directs the development of corrective action plans relating to program, policy, and staff performance improvements, as required
Child Protective Investigator
Department of Children and Families
12.2011 - 08.2013
- Intense investigations regarding child abuse, neglect and abandonment
- Served as point of contact for families with allegations of abuse or neglect
- Provided counsel by educating families and children about child protection
- Responded to hotline reports and determined immediate risk to child
- Assisted with child safety assessments
- Provided support by opening, maintaining and closing files related to families being served
- Reported indication of abuse, neglect and/or abandonment to Florida Abuse Hotline
- Arranged emergency placement for children at risk
Correctional Deputy
Brevard County Sheriff’s Department
03.2008 - 01.2012
- Reported and responded to unusual inmate behaviors or physical conditions
- Monitored facility while enforcing security, rules, regulations and procedures
- Resolved conflicts, grievance, and confrontations in a constructive manner where I established control and safety of inmates involved to minimize negative personal impact and confusion
- Assisted with investigative reports by employing clear and accurate findings
- Accurately documented records and maintained inmate information, records and logged various activities
- Provided intake and assignment of beds within the facilities
- Provided care, custody, control of inmates within the facilities
- Transported inmates to and from required locations
- Assisted with the counseling with inmates
- Served as Officer in Charge (OIC), facilitating the day to day operations of the jail facility on an as needed basis
Education
Bachelor of Science - Business Administration
University of Central Florida
Orlando, FL12-2011
Skills
- Problem-solving abilities
- Customer Service
- Patient contact
- Data entry skills
- Strong computer skills
- Critical Thinking Capabilities
- Claims
- Coverage assessments
- Settlement determinations
- Claims analysis
- Inspection report review
- Liability denials
- Complex claims consulting
- Multitasking Abilities
- Documentation skills
- Team building
- Policy Interpretation
- Denied claims identification
- Documentation processing
- Policy analysis
- Multitasking
- Reliability
- Fraud Detection
Timeline
Claims Specialist Int
Progressive Insurance
09.2019 - Current
Medical Claims Rep
Progressive Insurance
05.2018 - 09.2019
Child Protective Investigator Supervisor
Department of Children and Families
08.2013 - 05.2018
Child Protective Investigator
Department of Children and Families
12.2011 - 08.2013
Correctional Deputy
Brevard County Sheriff’s Department
03.2008 - 01.2012
Bachelor of Science - Business Administration
University of Central Florida
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