Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic
Kiesha Hearn

Kiesha Hearn

Locust Grove,GA

Summary

Analytical and detail-oriented claims expert with 9+ years of experience in property, casualty, bodily injury, and long-term care claims. Proven success in underwriting support, risk assessment, claims adjudication, and cross-functional collaboration. Adept at reviewing high-value claims for underwriting accuracy, ensuring compliance with insurance regulations, and minimizing loss exposure. Strong proficiency in policy interpretation, reserve analysis, and claims lifecycle management. Exceptional communicator with a sharp eye for identifying trends and recommending coverage decisions aligned with underwriting guidelines.

Overview

17
17
years of professional experience
1
1
Certification

Work History

Senior ltc claims payment servicing

Genworth Longterm Care
12.2024 - Current
  • Review, approve, and process high-dollar long-term care benefit payments in alignment with policy underwriting criteria and regulatory standards.
  • Apply critical thinking and advanced problem-solving skills to adjudicate complex claims and execute transactions based on contractual and policy details.
  • Identify trends and document processing errors to support quality improvement efforts and provide actionable feedback to leadership.
  • Manage multiple priorities in a fast-paced environment, consistently meeting aggressive deadlines and maintaining high service standards.
  • Partner with cross-functional teams including QA, IT, Compliance, and Eligibility to drive process enhancements and share best practices.
  • Make sound business decisions in complex or non-standard claims situations, using critical thinking and policy interpretation.

Senior Bodily Injury & property Claims Adjuster

State Farm
01.2023 - 12.2024
  • Managed 150+ complex bodily injury and property claims, reducing average settlement time by 30% through strategic action plans.
  • Investigated and settled property damage claims, conducted on-site inspections, reviewing repair estimates, and negotiating with contractors and vendors to secure cost-effective resolutions.
  • Coordinated property repair or replacement processes with outside partners, achieving a 95% on-time settlement rate and reducing overall resolution delays.
  • Identified and mitigated potential fraud, subrogation, and recovery opportunities, successfully minimizing total claim costs and securing additional reimbursement.
  • Led legal defense coordination, reducing litigation costs by 25% and recovering $500,000 through subrogation efforts, lowering total claim costs by 17%.
  • Maintained clear communication with attorneys and claimants (calls, emails, and texts), contributing to a 97% customer satisfaction rate.

Licensed Medicare field Sales Agent

Humana, Inc.
07.2021 - 06.2024
  • Conducted needs assessments and offered 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.
  • 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.

Senior Quality Assurance Specialist

e-Tele Quote Insurance, Inc.
02.2020 - 06.2021
  • Proactively requested and evaluated necessary records, maintaining effective communication with injured workers, medical professionals, and employers to monitor treatment plans and claim statuses.
  • Assessed and authorized claim payments, evaluated settlement opportunities, and determined claim resolutions based on comprehensive findings.
  • Collaborated with General Liability teams to enhance mitigation strategies, attended key meetings to monitor project risks, and maintained robust communication with carriers and Third-Party Administrators.
  • Provided feedback and training on documentation and coding practices, ensuring alignment with CMS guidelines and healthcare regulations.

Human Resources Administrative Specialist

AT&T, Inc.
10.2008 - 10.2020
  • Processed applicable disability claim forms efficiently and effectively with the disability carrier and provide necessary updates to the impacted individual.
  • Assiduously maintained and recuperated employee benefit premiums during leaves, safeguarding company resources and employee benefits.
  • Spearheaded strategic leave management initiatives, administering FMLA, disability, workers' compensation, and state-mandated leaves by updating policies and enhancing procedures in line with federal and state laws.
  • Manage relationships with benefits consultants, leave administrators, and other vendors to ensure seamless administration of programs and secure data management.
  • Developed and disseminated educational material, organized workshops, and conducted seminars to enhance employee understanding and engagement with benefits and leave options, significantly improving program utilization and satisfaction.

Member service Advocate | Claims Examiner

United Health Group
10.2015 - 10.2019
  • Verify and document insurance eligibility, benefits, and coverage for all office visits and infusion services. Secure necessary insurance authorizations and pre-certifications.
  • Implement insurance denial mitigation strategies, including facilitating peer-to-peer reviews and managing appeals.
  • Accurately calculate and communicate patient financial responsibilities, and provide support in accessing financial assistance programs, including patient assistance and manufacturer copay assistance.
  • Applied medical coding ability (ICD-10, CPT, HCPCS) to assess claim charges and medical necessity, determining payment or denial.
  • Monitor and managed STARs measure performance, focusing on DSNP/Medicare quality and related performance metrics. Report progress, challenges, and opportunities to the health plan’s leadership team regularly.
  • Managed Medicare and Medicaid member grievances and appeals, focusing on prior authorization denials and transportation issues.

Education

Bachelor of Science - Business Administration

Walden University

Skills

  • Claims analysis and resolution
  • Risk analysis and mitigation
  • Regulatory compliance expertise
  • Adjudication & Benefit Calculation
  • Claims Lifecycle management
  • Data- Driven Decision Making
  • Settlement negotiation expertise
  • Reserve Setting & Adjustment
  • Quality Assurance & SOP Adherence
  • Medicare & Medicaid Claims

Certification

  • FL 0620 - ADJUSTER (ALL LINES)
  • FL 0215 - LIFE (Incl. Variable Annuity & Health)

Timeline

Senior ltc claims payment servicing

Genworth Longterm Care
12.2024 - Current

Senior Bodily Injury & property Claims Adjuster

State Farm
01.2023 - 12.2024

Licensed Medicare field Sales Agent

Humana, Inc.
07.2021 - 06.2024

Senior Quality Assurance Specialist

e-Tele Quote Insurance, Inc.
02.2020 - 06.2021

Member service Advocate | Claims Examiner

United Health Group
10.2015 - 10.2019

Human Resources Administrative Specialist

AT&T, Inc.
10.2008 - 10.2020

Bachelor of Science - Business Administration

Walden University

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