Latynia Jones
Summary
Analytical Claims Specialist with proven experience investigating and resolving property, health, and business claims. Delivers professional and balanced customer service and meets the needs of insured, claimant, and internal and external customers. Insurance expert with exceptional knowledge of legal liabilities and claims practices and superior interpersonal skills.
Overview
8
8
years of professional experience
Work History
Stop Loss Claims Examiner
Symetra
09.2022 - Current
- Process an average of 6 to 10 claims daily including Initial and subsequent claim reimbursements within established turnaround goals
- Determine, on a timely basis, the eligibility of the assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim
- Review and adjudicate claims within approved authority limits
- Maintain assigned claim block and assist other team members while meeting departmental guidelines
- Interact with third-party administrators and other contacts to obtain information needed to make reimbursement decision
- Document rationale of claim decisions based on review of the contractual provisions, plan specifications, and the analysis of medical records, etc
- Conduct reconciliations for the end of the plan year for claim block of business
Pricing Support Analyst Lead
Elevance Health
09.2021 - 09.2022
- Trained new hires on Facets, Macess, and NextGen systems
- Audited processed claims for accuracy
- Organized workload and delivered to team members.
- Provided clear communications to team members regarding any process changes.
- Worked closely with other teams and departments to ensure proper and accurate claims resolutions.
- Accurately processed claims according to policy provisions
- Applied state specific plan benefits claims processing.
Pricing Support Analyst II
Elevance Health
03.2016 - 09.2021
- Maintained reimbursement data for the accurate processing of claims for several Health Plan markets
- Reviewed suspended claims for moderate-to-high volume/complexity markets or professional claims to determine the reason for pending and enacts appropriate action to resolve the pended claim
- Received claims pend inquiries from operations
- Analyzed contracts for their rates and products
- Conducted pricing/fee schedule/agreement/rate sheet validation to accurately and promptly price the pended claims
- Promptly responded to appeals, inquiries, and requests from the Health Plan
- Trained new hires
Education
Associates of Science in Health Science – Healthcare Technolology Systems -
Ultimate Medical Academy
07.2020
Skills
- Claims Processing
- Microsoft Office Suite
- Database Management
- Insurance knowledge
- Facets
- Contract Review
- Plan Policy Review
- Analytical Skills
Timeline
Stop Loss Claims Examiner
Symetra
09.2022 - Current
Pricing Support Analyst Lead
Elevance Health
09.2021 - 09.2022
Pricing Support Analyst II
Elevance Health
03.2016 - 09.2021
Associates of Science in Health Science – Healthcare Technolology Systems -
Ultimate Medical Academy