Kiara Williams
Savannah,GA
Summary
Detail-oriented and highly analytical Senior Claim Benefit Specialist with 7+ years of experience adjudicating complex medical, dental, and pharmacy claims within Medicare, Medicaid, and commercial insurance plans. Skilled in navigating systems such as Facets, Macess, Salesforce, DG, and ClaimsXten, applying ICD-10, CPT/HCPCS, CMS, and state-level compliance guidelines. Proven track record in resolving escalated claim issues, managing appeals, and mentoring claim processors. Expertise in SLA compliance, coverage determinations, cost share analysis, and appeals/grievance workflows. Committed to CVS Health's mission to deliver compassionate, connected, and compliant healthcare service.
Overview
13
13
years of professional experience
Work History
Lead Claims Adjudicator
AllState
03.2020 - 05.2025
- Adjudicate 650+ complex claims/month including inpatient, outpatient, DME, and pharmacy using Facets and DG with 99.8% accuracy.
- Process coverage determinations and eligibility verifications, reducing rework volume by 34% YoY.
- Manage escalated claim appeals, resolving 92% of issues without need for secondary review.
- Apply CMS, ERISA, and HIPAA compliance across all claim actions, passing 100% of internal audits.
- Train and mentor junior claim benefit specialists, improving team productivity by 19%.
- Flag $78,000+ in overpayments through root cause analysis and cost containment measures.
- Deliver timely documentation via Salesforce, maintaining 100% SLA compliance.
- Perform work calculations and authored detailed case documentation for compliance audits.
Senior Medical Claims Processor
Medicare Advantage
01.2017 - 02.2020
- Processed 400+ Medicare Advantage and self-funded claims/week with adherence to CMS and NCQA standards.
- Handled Tier 2 escalations, successfully re-adjudicating 95% of incorrectly denied claims.
- Conducted coverage analysis and eligibility checks across POS, PPO, and HMO plans.
- Coordinated with providers via outbound calls to collect pre-authorization documentation.
- Reviewed CPT/ICD-10 coding accuracy on high-dollar claims exceeding $10,000.
- Contributed to workflow optimization project, reducing average turnaround time by 28%.
- Used Macess and ClaimsXten to document case activity and automate claims scoring.
- Identified 150+ claim irregularities, triggering SIU reviews for fraud, waste, and abuse (FWA).
Benefit Resolution Specialist
Miles Mediation & Arbitration
08.2014 - 12.2016
- Adjudicated dental and medical claims using AMISYS and NASCO, with a 98.5% QA pass rate.
- Handled inquiries, appeals, and grievances via call and written communication for HMO/PPO plans.
- Interpreted EOBs and fee schedules to process retroactive claims and perform COB adjustments.
- Monitored daily claim queues, managing over 1,200 claim lines/week.
- Documented case outcomes and corrective actions in Salesforce and HealthEdge.
- Provided member education on benefit plan structure and cost-sharing.
- Acted as liaison to care management and prior auth teams for claim eligibility.
- Identified $45,000+ in systemic underpayments and collaborated with audit team to recover funds.
- Developed training materials for new team members, ensuring consistent knowledge transfer.
Medical Claims Analyst
CVS Healthcare
01.2012 - 08.2014
- Supported Medicaid and Medicare plans with daily adjudication of 350+ claims via Facets and Macess.
- Maintained 100% SLA compliance for TAT and accuracy benchmarks.
- Reviewed pre-authorization and medical necessity documentation per HEDIS/CMS criteria.
- Processed appeals and reconsiderations, delivering detailed written explanations for claim decisions.
- Tracked and trended claims error reports, reducing denial volume by 15% through re-training initiatives.
- Participated in internal quality review and peer mentorship, maintaining 99% team accuracy.
- Conducted provider outreach to clarify diagnosis coding and update patient records.
- Facilitated FWA cases to compliance, resulting in over $27K in recovered funds.
Education
HIPAA Certification - undefined
Compliancy Group
Certified Customer Service Professional - undefined
CCSP
Service Excellence Certificate - undefined
CVS Health “Heart at Work”
Medical Terminology Certificate - undefined
Coursera
Conflict Resolution in Healthcare - undefined
Udemy
Skills
- Claims Adjudication
- Medicare/Medicaid Processing
- CPT/ICD-10/HCPCS Coding
- Coverage Determination
- Claims Rework & Adjustment
- Appeals & Grievances
- Root Cause Analysis
- Fraud, Waste & Abuse (FWA)
- Coordination of Benefits (COB)
- Medical Necessity Review
- CMS & HIPAA Compliance
- Cost Share Analysis
- Eligibility Verification
- SLA & TAT Monitoring
- Claims Escalation Handling
- Self-Funded Plan Experience
- Complex Claims Analysis
- Member Communication
- Benefit Plan Interpretation
- Audit Documentation
SOFTWARE/SYSTEM EXPERTISE
- Facets
- Macess
- Salesforce
- DG System
- AMISYS
- ClaimXten
- HealthEdge
- Microsoft Excel & Access
- NASCO
- MedHOK
Timeline
Lead Claims Adjudicator
AllState
03.2020 - 05.2025
Senior Medical Claims Processor
Medicare Advantage
01.2017 - 02.2020
Benefit Resolution Specialist
Miles Mediation & Arbitration
08.2014 - 12.2016
Medical Claims Analyst
CVS Healthcare
01.2012 - 08.2014
HIPAA Certification - undefined
Compliancy Group
Certified Customer Service Professional - undefined
CCSP
Service Excellence Certificate - undefined
CVS Health “Heart at Work”
Medical Terminology Certificate - undefined
Coursera
Conflict Resolution in Healthcare - undefined
Udemy
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