Summary
Overview
Work History
Education
Skills
Timeline
Generic
Lindsey Williams

Lindsey Williams

Austin,TX

Summary

Experienced, dedicated, and driven specialist who has strong time management, prioritization, and problem solving skills. Effectively, monitors and manages quality disability claims, state and federal leaves, according to standard company procedures and practices, statutory and regulatory requirements. Skillfully and timely conducts case assessments; interviewing, investigating, analyzing, obtaining and documenting records, reaching sound supported conclusions on claims while exceeding customer service expectations. Experience providing case management services for a large, multi-state employer and on behalf of a third party administrator.

Overview

22
22
years of professional experience

Work History

Claim Benefit Specialist Ops

CVS AETNA
10.2024 - 03.2025
  • Handles and processes Benefits claims submitted by healthcare providers, ensuring accuracy, efficiency, and strict adherence to policies and guidelines.
  • Determines the eligibility and coverage of benefits for each claim based on the patient's insurance plan and policy guidelines and scope.
  • Assesses claims for accuracy and compliance with coding guidelines, medical necessity, and documentation requirements.
  • Documents claim information in the company system, assigning appropriate codes, modifiers, and other necessary data elements to ensure accurate tracking, reporting, and processing of claims.
  • Conducts reviews and investigations of claims that require additional scrutiny or validation to ensure proper claim resolution.
  • Communicates with healthcare providers, patients, or other stakeholders to resolve any discrepancies or issues related to claims.
  • Determines if claims processing activities comply with regulatory requirements, industry standards, and company policies.
  • Develops and implements regular, timely feedback as well as the formal performance review process to ensure delivery of exceptional services and engagement, motivation, and team development.
  • Analyzes claims data and generate reports to identify trends, patterns, or areas for improvement to help inform process enhancements, policy changes, or training needs within the claims processing department.
  • Reviews and adjudicates claims in accordance with claim processing guidelines.
  • Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment measures to assist in the claim adjudication process.
  • Review claims or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.
  • Analyzes and processes rework claims that cannot be auto adjudicated.
  • In accordance with prescribed operational guidelines, manages route list/queues.
  • Utilizes all applicable system functions available ensuring accurate and timely claim processing service.

Absence Management Specialist II

Matrix Absence Management
08.2021 - 11.2023
  • Processes complex leave of absence with short term disability claims in timely compliance with the corresponding leave plans, federal and state laws and benefit plans as defined by the client.
  • Responds to inquiries about leave and disability events, benefits, and options available to employees.
  • Amends, sends, and files required claim documents to fulfill employers obligations such as approval/denial correspondence, delay letters.
  • Collaborates with team members on claim files and other projects.
  • Accurately codes all system fields with correct financial, diagnosis and duration information.
  • Ensures employee aware of return to work process and helps facilitate smooth returns to work by working with client/employee/ADA specialist on any workplace accommodations/forms/information needed.
  • Coordinates with other departments to ensure appropriate claims transition.
  • Documents claim updates in the claim database ensuring accuracy.
  • Maintaining departmental and policyholder expectations.
  • Adheres to compliance, departmental procedures, and Unfair Claims Practice regulations.
  • Actively contributes to, and maintains, customer service, quality and performance objectives.
  • Proactively engages in departmental trainings to remain current with all claim management practices.
  • Responsible for managing Performance Guarantees for assigned clients
  • Responsible and accountable for maintaining and protecting personal, confidential claimant health information. Maintains a high level of confidentiality and abide by HIPPA rules and regulations.

Texas Works Advisor II

Texas Health And Human Services Commission
09.2018 - 10.2020
  • Performed complex and quality case eligibility determinations of social service programs, such as SNAP, MEDICAID, and TANF, whilst applying pre-adjudicating and ongoing case analysis to client statements and documentation.
  • Addressed questionable information and created fraud alert referrals to OIG when necessary.
  • Review cases for accuracy and completeness of data and interact with providers and clients.
  • Perform research for information discrepancies as identified by providers or client.
  • Create member authorizations for approved eligibility services.
  • Verify member eligibility prior to authorizing services.
  • Coordinate with eligibility staff for member eligibility discrepancies and update system as necessary.
  • Work involves interviewing clients of culturally diverse backgrounds during times of crisis and distress, documenting detailed information, verifying case data, reviewing eligibility files, explaining program benefits, and rights and requirements to clients.
  • Assessing client and/or family situation to guide client to appropriate programs available to help client on the path of self-sufficiency.
  • Proficiency with computers and data entry into electronic tracking systems.
  • Call center telephony position requiring abundant amounts of answering incoming and outbound calls daily.
  • Resolves complaints and escalated issues.
  • Elicits, evaluates, researches, and validates information with critical thinking and sound judgement.
  • Document’s case records, maintains confidential, secure and accurate client information in case management software system with professionalism and discretion.
  • Processes, monitors, reviews, and communicates case status to client, their families and authorized representatives.
  • Obtains, verifies, and calculates client income and resources to determine financial eligibility for social service programs.
  • Ability to quickly adapt to change with positive energy and attitude.
  • Meets quality assurance and other key performance metrics such as deadlines and processing timeframes.
  • Established strong and positive relationships with coworkers and supervisors.
  • Processes follow up information that client case was pended for.
  • Escalated important information and situations to appropriate delegates in a timely manner.
  • Aspired clients through business knowledge and reliability by initiating and following through with urgency for client solutions.
  • Ability to use appropriate level of empathy whilst being direct with individual.
  • Worked proficiently while completing heavy workloads.
  • Being self-regulated and remaining composure during uncomfortable interactions.
  • Executive and certain decision making.
  • Operated with a sense of urgency, integrity, and expectations for client experience.
  • Worked with internal and external agencies.

Team Lead

JCP
09.2010 - 09.2013
  • Anticipated customer needs with active listening and critical thinking.
  • Trained, mentored, and coached all cashier associates on checkout procedures to ensure outstanding service behaviors were consistently exhibited. Regularly observed and ensured associates consistently followed and implemented checkout experience processes, if not utilized exploration of root cause
  • Monitored associate efficiency by utilizing Point of Sale productivity metrics.
  • Supervised over 20 associates during manager on duty schedule.
  • Performed exceedingly passing product metrics on regular basis.
  • Established positive working relationships with associates and other supervisors.
  • Accountable for driving customer service to achieve profitable sales growth by leading and engaging associates, delivering company checkout experience strategies and processes, and coaching associates on customer service.
  • Adapted quickly to changing situations with energy and positive attitude. Coached others through change.
  • Empathically served needs of customers and associates; listened well; seeked to understand diverse points of view to help find best solution or outcome: provided helpful assistance to others; pursued high standard of performance.
  • Held self and others accountable to higher standard to achieve results. Provided feedback, visibility and recognition to team.
  • Operated with a sense of urgency, integrity, and expectations for client experience.

Customer Service Manage Department Manager

Wal Mart
06.2003 - 09.2010
  • Utilized fraud prevention strategies.
  • Reacted quickly and efficiently when any loss prevention or fraud situations occurred.
  • Informed and educated loss prevention on specific fraud situations.
  • Established efficient workflow processes, monitored daily productivity, and implemented modifications to improve overall effectiveness of personnel and activities.
  • Conducted interviews, hired, trained, and evaluated associates.
  • Managed over 4 departments and 50 associates.
  • Software and program maintenance and use.
  • Oversaw appointment scheduling and itinerary coordination for both clients and personnel.
  • Established and updated work schedules to account for changing staff levels and expected workloads.
  • Maintained accurate, current, and compliant financial records by monitoring and addressing variances.
  • Hired, managed, developed, and trained staff, established, monitored goals, and conducted performance reviews.
  • Provided high level of assistance to customers regarding special photo projects.
  • Maintained lab printers and processing equipment, ensuring proper functioning for each shift.
  • Oversaw office inventory activities, including ordering and requisitions, stocking and shipment receiving. Also notified loss prevention of any discrepancies when appropriate.
  • Operated with a sense of urgency, integrity, and expectations for client experience.

Education

Social Work

Austin Community College
Austin, TX
12-2025

General Studies

Howard College
Big Spring, TX

General Studies

Angelo State University
San Angelo, TX

Skills

  • Strong Problem Solving
  • Time Management
  • Prioritization
  • FMLA/ADA Knowledge
  • Self Motivated
  • Effective Interpersonal
  • Detail-Oriented
  • Multitasking
  • Cognitive flexibility, Adaptation to Change
  • Trouble Shooting
  • Collaborative and Creative
  • Executive Problem and Complaint Resolution
  • Customer Service
  • Microsoft Office, Excel, Word, and Teams

Timeline

Claim Benefit Specialist Ops

CVS AETNA
10.2024 - 03.2025

Absence Management Specialist II

Matrix Absence Management
08.2021 - 11.2023

Texas Works Advisor II

Texas Health And Human Services Commission
09.2018 - 10.2020

Team Lead

JCP
09.2010 - 09.2013

Customer Service Manage Department Manager

Wal Mart
06.2003 - 09.2010

General Studies

Howard College

General Studies

Angelo State University

Social Work

Austin Community College

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