Khaliah Jones
Houston
Summary
Detail-oriented Claims Benefit Specialist with over four years of experience in processing and managing insurance claims. Proficient in medical coding, benefits administration, and claims investigation, with a strong focus on accuracy and compliance. Exceptional communication and customer service skills, coupled with a proven ability to resolve conflicts and collaborate effectively with team members. Adept at navigating complex policies and providing thorough documentation and reporting to ensure efficient claims processing.
Overview
5
5
years of professional experience
Work History
Claim Resolution Specialist
Ovation Healthcare
09.2023 - Current
- Utilize industry-standard software and tools to document claim details, process transactions, and generate comprehensive reports for internal and regulatory purposes.
- Ensure compliance with company policies, legal requirements, and industry regulations while maintaining high levels of customer satisfaction and service quality.
- Provide expert guidance and support to policyholders throughout the claims process, addressing inquiries, resolving issues, and offering solutions to enhance the overall customer experience.
- Investigate and resolve complex insurance claims by analyzing policy coverage, medical records, and supporting documentation to ensure accurate and timely
- Communicate with policyholders, medical providers, and internal departments to gather necessary information and provide updates on claim statuses.
Benefits Claims Analyst
Sunbelt Health Partners
04.2022 - 09.2023
- Review and verify claimant information, medical records, and policy details to determine eligibility and calculate benefit amounts.
- Communicate with claimants, healthcare providers, and insurance representatives to gather necessary documentation, clarify policy terms, and resolve any issues or discrepancies.
- Analyze and assess benefit claims to ensure compliance with policy guidelines and regulatory requirements, processing claims accurately and efficiently.
- Identify and investigate potential fraud, errors, or inconsistencies in claims, taking corrective action as necessary to maintain integrity and accuracy.
- Prepare detailed reports and documentation on claim status, approvals, denials, and adjustments for internal review and regulatory compliance.
- Provide expert guidance and support to claimants regarding benefit entitlements, claim procedures, and policy information, ensuring a high level of customer service and satisfaction.
Claims Processing Specialists
Meduit
06.2020 - 04.2022
- Perform audits on processed claims to ensure compliance with company policies, regulatory requirements, and industry standards, making adjustments as needed.
- Analyze and interpret insurance policies, medical records, and claim forms to determine eligibility, benefits, and appropriate claim outcomes.
- Review and process insurance claims by verifying coverage details, assessing claim validity, and calculating appropriate benefit amounts to ensure accurate and timely settlements.
- Provide exceptional customer service by addressing inquiries, offering support throughout the claims process, and facilitating a positive resolution for claimants.
- Input and update claim information into industry-standard software systems, maintaining accuracy and completeness of records for efficient processing and reporting.
- Communicate with claimants, healthcare providers, and internal teams to obtain necessary documentation, clarify policy terms, and resolve any discrepancies or issues.
Education
High School Diploma -
Morton Ranch High School
Katy, TX06-2014
Skills
- Claims investigation
- Compliance knowledge
- Documentation & reporting
- Analytical Skills
- Medical coding
- Insurance verification
- Efficient and detail oriented
- Call Documentation
- Order and Refund Processing
- Data Entry
- Conflict resolution
- Policy coverage expert
Timeline
Claim Resolution Specialist
Ovation Healthcare
09.2023 - Current
Benefits Claims Analyst
Sunbelt Health Partners
04.2022 - 09.2023
Claims Processing Specialists
Meduit
06.2020 - 04.2022
High School Diploma -
Morton Ranch High School
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