Linda Smith
Miami
Summary
Accomplished, results-driven professional with extensive experience in medical insurance, particularly within the Latin American market. Skilled in processing both domestic and international claims, including complex cases. Experienced in underwriting standard to complex policies to achieve new business, renewal goals, and policy changes. Cross-functional expertise in claims processing, customer service, case manager assistant, processor, enrollment, and general administration. Possess knowledge of medical records and demonstrate excellent organizational, analytical, and problem-solving skills.
Overview
20
20
years of professional experience
1
1
Certification
Work History
Claims Processor
Global Reach Health
01.2020 - 01.2025
- Examine submitted claims for accuracy, completeness and compliance with coding and guidelines and insurance policies.
- Process claims (domestic and/or internationals) and/or claim adjudications including direct payments and/or reimbursements with high level of productivity and accuracy and adhere to company process, procedures and guidelines.
- Review policy to see notes and policy comments for pre-authorizations, exclusions, limitations, pre-existent conditions, or higher deductibles for specific conditions.
- Confirm patient eligibility and benefits based on their insurance plan.
- Accurately enter claim information in systems and maintain organized records.
- Investigate and resolve discrepancies, denials and other claim-related issues.
- Ensure adherence to healthcare regulations, industry standards and company policies.
- Maintain accurate and up-to-date records of claims, communications and other relevant information.
- Determines if claims submitted are subject to coordination of benefits from other insurance coverage.
- Experienced working under pressure, allowing me to process over 1000 claims per month.
- As a TPA member, this allowed me to worked with several networks including Aetna and UHC.
- Responds to emails/calls in a professional, diplomatic and tactful manner in order to achieve a positive customer experience with every interaction with both internal and external customers.
Customer Service Representative
BUPA INSURANCE COMPANY
01.2018 - 01.2020
- Review emails to verify all of the information requested by the client is enough and sort it out accordingly.
- Call center for mostly Mexico and also Latin America and the Caribbean.
- Provide information to the clients, agents and providers regarding their applications, claims, commissions, changes and authorizations for medical services.
- Analyze information received in order to send it to the adjustment team to reprocess claims.
- Work together with all departments in order to provide accurate information to the client.
- Follow up on delicate and complex cases that have to be discussed in depth with the management team.
- Provided assistance and back up to the changes team and managed to decrease the TAT on automatic changes for policies.
- Managed to reduce the amount of calls coming in by keeping the changes in 24-48 hours.
- Oriented the clients to become more internet users, in order to reduce the amount of calls.
- Review all of the information received for an appeals case and set it up for the committee.
Health Underwriter
BUPA INSURANCE COMPANY
01.2005 - 01.2018
- Supported review and acceptance or denial of new Business and changes in policies.
- Reviewed applications for insurance coverage and reports to determine risks.
- Addressed average of 30 customer inquiries and complaints each day.
- Reported policy changes and company conditions affecting customer satisfaction.
- Negotiated new and renewal production goals with business development manager.
- Supported Medical Underwriting team by ensuring that medical records and other information requested was received correctly and in timely manner.
- Supported Medical Team with Notification: review and acceptance or denial of new business or changes in policies.
- Reviewed applications and Data-Entry.
- Addressed average of 40 customer inquiries and complaints each day.
- Reported policy changes and company conditions affecting customer satisfaction.
- Supported Underwriting team by ensuring that medical records and other information requested was received correctly and in timely manner.
Education
Technology - farming and animal administration
Universidad de Santa Rosa de Cabal “UNISARC”
Business Administration - undefined
Universidad Catolica de Pereira
Laboratory - Bacteriology
Universidad Catolica de Manizales
Skills
- Effective relationship management
- Data analysis
- Identifying new business opportunities
- Customer satisfaction management
- Proficient in medical terminology
- Clinical interviews
- Experience with object-oriented methodologies
- Goal-oriented
- Effective multitasking
- Fluent in two languages
- Attention to detail
- Claims analysis
Languages
Spanish
Native or Bilingual
Certification
- LOMA courses: 280 Principles of Insurance; Underwriting Life and Health Insurance 386 UND; Principles of Reinsurance.
- Medical Terminology courses.
Timeline
Claims Processor
Global Reach Health
01.2020 - 01.2025
Customer Service Representative
BUPA INSURANCE COMPANY
01.2018 - 01.2020
Health Underwriter
BUPA INSURANCE COMPANY
01.2005 - 01.2018
Business Administration - undefined
Universidad Catolica de Pereira
Laboratory - Bacteriology
Universidad Catolica de Manizales
Technology - farming and animal administration
Universidad de Santa Rosa de Cabal “UNISARC”
Similar Profiles
Aleyda AbreutAleyda Abreut
Claims & Customer Service Manager at Global Reach HealthClaims & Customer Service Manager at Global Reach Health
DALIA CARVAJALDALIA CARVAJAL
Medical Coordinator at Global Reach HealthMedical Coordinator at Global Reach Health
Mausumi AichMausumi Aich
Sr. Executive (Counselling) at Global ReachSr. Executive (Counselling) at Global Reach
Thelma O. PytonThelma O. Pyton
Behavioral Health Targeted Case Manager at Healthy Connections CMHC, INC. , Behavioral HealthBehavioral Health Targeted Case Manager at Healthy Connections CMHC, INC. , Behavioral Health
Anthony PuertoAnthony Puerto
Lead Valet Attendant, Busser, Food Runner at Nandos GrillLead Valet Attendant, Busser, Food Runner at Nandos Grill