Kiesha Hearn
Summary
Versatile Claims Adjuster with over nine years of experience managing complex claims, including litigated and non-litigated cases. Skilled in negotiating settlements, ensuring regulatory compliance, and improving operational efficiency. Strong knowledge of Self-Insurance regulations, Case Law, and the Labor Code, with expertise in claims administration and reserve management. Proficient in data analysis, mathematical calculations, and clear communication across all levels, including presentation to management, excellent time management, critical thinking skills, and delivering superior customer service.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Senior Bodily Injury Claims Adjuster
State Farm
03.2024 - 01.2025
- Efficiently managed over 200 complex bodily injury claims, achieving a 30% reduction in settlement time through strategic action plans and enhanced resolution efficiency
- Coordinated legal defense, assigning attorneys, and supporting investigations, ensuring compliance with client guidelines
- Identified and mitigated potential fraud, subrogation, contribution, and recovery opportunities, minimizing total claim costs
- Led legal defense coordination, reducing litigation costs by 25% and recovering $500,000 through subrogation opportunities, cutting total claim costs by 16.9%
- Estimate costs of repair, replacement, or compensation
- Facilitated communication with attorneys and claimants via calls, emails, and texts, ensuring clear and comprehensive case resolutions, contributing to a customer satisfaction rate increase of 97%
Licensed Medicare Sales Agent
Humana, Inc.
07.2021 - 06.2024
- Conducted needs assessments and provided coverage options in compliance with CMS regulations, achieving sales targets and enhancing customer satisfaction
- Presented and explained policy benefits, terms, and coverage details to clients, achieving or exceeding sales targets
- Enhanced lead conversion rates by 35% utilizing advanced CRM systems and data-driven sales techniques, proficiently managing objections and closing deals
- Maintained compliance with client records (89%), prepared reports, and utilized CRM systems for lead management
- Exceeded sales targets by 40% through strategic client engagements, increasing customer satisfaction by 20%
- Utilized CMS platforms to verify Medicare eligibility, ensuring accurate client service and adherence to federal guidelines
Licensed Quality Assurance Specialist
e-Tele Quote Insurance, Inc.
05.2020 - 06.2021
- Amplified Medicare enrollments by articulating plan benefits and options to clients
- Presented and explained policy benefits, terms, and coverage details to clients, achieving or exceeding sales targets
- Fostered relationships with healthcare providers to enhance referral networks
- Provided feedback and training on documentation and coding practices, ensuring alignment with CMS guidelines and healthcare regulations
- Conducted quality checks, identified, and corrected mislabeled dates, and provided feedback to annotation teams
- Participated in annotation audits to uphold data quality and minimized model bias by following precise labeling criteria
Quality Assurance Lead
AT&T, Inc.
10.2008 - 10.2020
- Mentored 15 QA specialists, improving project delivery timelines by 15% and reducing defect rates by 30% through leadership and continuous improvement initiatives
- Implemented continuous improvement initiatives within the QA team to elevate performance levels consistently across projects over time
- Spearheaded a program that boosted cross-departmental process efficiency by 25%, aligning QA efforts with the product development lifecycle
- Performed internal audits to maintain operating procedures and regulatory standards compliance
- Established performance benchmarks to measure the success of QA initiatives, driving further enhancements over time
- Acted as a key point of contact for all QA aspects of releases by providing QA services and coordinating QA resources internally and externally
Medicare & Medicaid Advocate | Claims Examiner
United Health Group
10.2015 - 10.2019
- Executed detailed risk assessments and damage appraisals, leading to a 13% reduction in claim overpayments and improving overall department cost efficiency
- Conducted audits to ensure compliance with industry standards, resulting in a 20% reduction in claim processing errors
- Analyzed data to identify quality trends and worked with cross-functional teams to implement solutions
- Maintained detailed audit trails by documenting physical files, updating electronic systems, and drafting notification letters, ensuring compliance with legal and SOP standards
- Applied medical coding expertise (ICD-10, CPT, HCPCS) to assess claim charges and medical necessity, determining payment or denial
- Managed Medicare and Medicaid member grievances and appeals, focusing on prior authorization denials and transportation issues
Education
Bachelor of Science - Healthcare Administration
Walden University
Associate of Science - Business Administration
Broward College
FL Certified All-Lines Adjuster -
Kaplan Financial Education
Skills
- Claims Investigation & Adjudication
- Risk Mitigation and Reserve Management
- Regulatory Compliance (HIPAA)
- Cross-Functional Collaboration
- Analytical and Problem-Solving Skills
- Time Management and Organization
- Negotiation Techniques
- Process Improvement
- Quality Assurance
- Medicare & Medicaid Expertise
Certification
- FL #W666747
- FL 0620 - ADJUSTER - ALL LINES
- FL 0215 - LIFE INCL VAR ANNUITY & HEALTH
- Georgia #3355666
Certifications And Skills
Microsoft Office Suite: Word, Excel, PowerPoint, G-Suite: Doc, Sheets, Forms, Slides, Technical Troubleshooting, FL Certified All-Lines Adjuster (CALA), Life INCL VAR ANNUITY & HEALTH
Timeline
Senior Bodily Injury Claims Adjuster
State Farm
03.2024 - 01.2025
Licensed Medicare Sales Agent
Humana, Inc.
07.2021 - 06.2024
Licensed Quality Assurance Specialist
e-Tele Quote Insurance, Inc.
05.2020 - 06.2021
Medicare & Medicaid Advocate | Claims Examiner
United Health Group
10.2015 - 10.2019
Quality Assurance Lead
AT&T, Inc.
10.2008 - 10.2020
Bachelor of Science - Healthcare Administration
Walden University
Associate of Science - Business Administration
Broward College
FL Certified All-Lines Adjuster -
Kaplan Financial Education
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