MELANIE WINZER JOSEPH
RICHMOND,TEXAS
Summary
Facilitated diverse clinical operations to support patient care across various health conditions.,Applied analytical skills in insurance and risk management to assist with business analysis tasks.,Pursued opportunities in claims adjusting within organizations that prioritize negotiation and analysis.
Overview
1
1
Certification
33
33
years of professional experience
Work History
liability determination
Allstate insurance
04.2026
- Main point of contact for insured, vendors, and adjusters throughout the claim process
- Made initial contact with insured and managed all ongoing communication
- Scheduled field adjusters based on location and claim volume
- Reviewed field reports and updated reserves to reflect accurate loss estimates
- Verified coverage and made claim decisions based on policy terms
- Issues claim payments and drafted all letters and documentation
- Handled settlement discussions and finalized claim resolutions
- Claims handling from the cradle to the grave
- Kept tasks and diary notes current to ensure timely file handling
- Reviewed and processed supplements when meet
- Properly documented all claim activities in the system
Medical Underwriter
United Health Group
06.2026 - Current
- A medical underwriter (or health insurance underwriter) evaluates an applicant's health status and medical history to assess risk, determine policy eligibility, and set premium rates for life, health, or disability insurance. Their goal is to balance company profitability with fair and accurate coverage.
- Auto Claims Resolution Specialist.
Compliance Department Customer Success Specialist / Underwriter / Quality Auditor
Acu-Serve
09.2024 - Current
- Medicare Claims Auditor Pre and Post Payment.
- Perform auditing of pre and post claims
- Perform coding of claims payable and accounts receivable claims
- Properly coding medical claims
- Conducting appeals and reviews of claims rejected not acceptable to CMS standards
- Managing claims access and customer service and providing client support
- Managing customer satisfaction by way of surveys or management
- Performing peer to peer audits and auditing other departments to ensure accuracy
- Following policy and procedures of CMS guidelines and maintaining regulatory standards
- Managing One Note and Excel Sheets with client information updating as well. Balancing company profitability with fair and accurate coverage.
- Evaluates an applicant's health status and medical history to assess risk, determine policy eligibility, and set premium rates for life, health, or disability insurance.
Auto Claims Department
Geico Insurance
10.2024 - 04.2026
- Resolves and resolves insurance claims by collecting facts
- Investigating details
- Communicating insurance claims with policy holders
- Handling customer inquiries
- Ensuring accuracy in claim processing and providing support to policy holders during the claims process
- Working in a fast-paced environment with high volume call center environment
- Strong customer service, communication, and multitasking skills
- Insurance claims by collecting facts, investigating details, and communicating Investigates with policyholders.
DME Consulting Customer Success Specialist Medical Underwriting
Optimal Respiratory and Sleep LLC
05.2019 - 08.2024
- Oversee the development and implementation of clinical adherence programs
- Closely monitor and guarantee adherence of new patients and providers
- Effectively serve as an auditor overseeing a team of seven direct reports, with a focus on ensuring strict compliance and facilitating the preparation of new contracts. Responsible for generating leads, managing marketing and advertising efforts, establishing new networks, and compiling reports
- Implement regulatory programming and coordinate with safety programs to ensure compliance with medical standards, thereby guaranteeing the safety of programs
- Facilitate telehealth video conferences with drivers, while performing virtual mask fittings and maintaining equipment
- Administer the recruitment and training of new employees, while monitoring daily activities of the health care call center, as well as conducting quarterly and annual employee performance reviews
- Led daily quality assurance audits to enhance team performance and ensure customer service satisfaction, while providing training to incoming staff on software and equipment
- Carefully follow up and perform customer service success outcomes
- Screening and assessing client conditions at risk for chronic illnesses applying for Medicare and UHC determination of risk levels
Provider Advocate/Customer Service-Contract Role
United Healthcare
09.2022 - 09.2023
- Built positive relationships between health plans and beneficiaries, providers, and practice managers by assisting with the design and implementation of programs
- Supported the creation of provider networks, as well as the implementation of training and development of external providers through educational initiatives
- Aided Network Contracting and Development teams in identifying gaps in network composition and services by simultaneously navigating through 19 systems with 3 screens
- Notable Accomplishments
- Assisted in the end-to-end processing of provider claims to enhance call quality, while contributing to various initiatives aimed at improving the usability of the physician portal and facilitating future service enhancements
Supervisor, Outreach Services/Customer Experience /Underwriter
Devoted Health
01.2021 - 02.2022
- Conducted health assessment on patient to identify proper equipment and health care interventions
- Rendered education and orientation to patients on preventative healthcare strategies to increase quality of health
- Effectively directed a team of 14 outreach specialists
- Ensured direct communication with doctors, discharge planners, and social workers for proper management
- Performed quality audits, as well as reviewed performance metrics and KPIs for team
- Led employee evaluations, interviews, and one-on-one assessments and producing job aides, SOPs
- Exhibit personal and communication skills to secure strong and professional bonds with client and patients
- Conducted customer service audits re service needs and expectations
- Screened patients for risk factors for diseases and for disease management
Manager/Head of Customer Service/Clinical Operations Program
Precision Sleep Solutions
05.2019 - 06.2021
- Keenly managed and ensured compliance of truck drivers with Department of Transportation (DOT) standard
- Oversaw the development and implementation of clinical adherence programs
- Acted as an auditor in charge of a team of seven focused on supporting strict compliance and preparation of DOT paperwork and reports
- Took charge of facilitating telehealth video conferences with drivers, performing virtual mask fittings, and maintaining equipment
- Led the recruitment and training of new employees, while tracking daily activities of the health care call center and performing quarterly and annual employee performance reviews
- Executed quality assurance audits daily for improved team performance and customer service satisfaction
Quality Assurance Specialist (Intern)
Cutting Edge Pipes
01.2018 - 01.2020
- Managed close supervision and inspection of product integrity to ensure safety and minimize flaws, aiming for zero defects
Interim Director/Population Health Manager/Lead Underwriter
Vitalis Health
03.2017 - 05.2019
- Carried out quality assurance audits daily to improve team performance and customer service satisfaction
- Conducted training and daily activities of the health care call center, while performing quarterly and annual employee performance reviews
- Formulated customized respiratory health plans for chronic pediatric and adult patients
- Guaranteed proper coordination of adherence and compliance program for patients
- Established standard operating procedures (SOPs) and workflows, while directing sleep program, securing patient satisfaction, and ensuring quality control over the equipment
- Provided health education to patients and other staff members
- Worked under the direct supervision of the vice president of healthcare and operations
- Took care of all customer and client needs
- Notable Accomplishments
- Earned fast-track promotion from population health manager to interim director of clinical operations
- Spearheaded the expansion of employment offer letters and execution of new employee orientation
- Successfully enhanced time management and streamlined company standards/policies in collaboration with the entire team to boost customer satisfaction and implement cost-saving strategies under the guidance of management
Director Operations
Royal Kid's Palace
01.1994 - 12.2016
- Strategically directed the overall operations, encompassing payroll, accounts payable, and menu management, while overseeing curriculum and other teachers activities
- Managed the marketing and advertisement of business, as well as facilitated interview of all prospective clients and possible new candidates
- Coordinated with state representative throughout the inspection
- Catered to the needs of customers re critical issues
Education
Master of Science - Public Health and Health Education
Columbia Southern University
Orange Beach, AL02.2020
Bachelor of Science - Health Prevention and Wellness
Rasmussen College
Bloomington, MN09.2017
Associate of Science - Respiratory Care and Therapy
San Jacinto College
Pasadena, TX05.2010
Skills
- Enhanced team efficiency through adept use of Microsoft Office applications, including Word, Excel, and Access
- Improved data accuracy and reporting through Brightree utilization
- Increased patient care efficacy with Epic system management
- Advanced sleep data analytics and reporting using Somni Sage
- Achieved seamless data operations utilizing CIMS
- Streamlined medical billing processes through Medisoft DME usage
- Facilitated efficient project collaboration using Google Suites
- Optimized payroll and time tracking using ADP
- Enhanced IT service delivery through Mindshift
- Improved patient care coordination with Care Orchestrator
- Increased sales efficiency with Salesforce implementation
- Enhanced therapy device management using ResMed systems
Certification
- License: Texas(DHS)
- Licensed Claims Adjuster
- Dedicated to accurately and ethically determining liability in insurance claims. Committed to avoiding litigation by ensuring fair settlements with claimants. Talented problem solver with high level of social competence and a passion for helping people in crisis. State Farm Auto Certifications, Pilot Auto Certifications
- Skills
- Policy Language Complex Claims, Xactimate/XactAnalysis, Symbility, Guidewire, Mitchell/CCC One, Litigation, File Review, Supplement Handling State Farm Auto Certification Pilot Auto Certification
Affiliations
- National Board for Respiratory Care (NBRC)
- American Association for Respiratory Care (AARC)
- Texas Medical Board
PROFESSIONAL DEVELOPMENT
- Healthcare Leadership Training
- Health Plan Development Training
ACTIVITIES
- Member, Safety Coach Committee
- President, Respiratory Morale Committee
- Member, Skin Champions Committee
- Member, Sigma Alpha Pi National Society of Leadership
Timeline
Medical Underwriter
United Health Group
06.2026 - Current
liability determination
Allstate insurance
04.2026
Auto Claims Department
Geico Insurance
10.2024 - 04.2026
Compliance Department Customer Success Specialist / Underwriter / Quality Auditor
Acu-Serve
09.2024 - Current
Provider Advocate/Customer Service-Contract Role
United Healthcare
09.2022 - 09.2023
Supervisor, Outreach Services/Customer Experience /Underwriter
Devoted Health
01.2021 - 02.2022
DME Consulting Customer Success Specialist Medical Underwriting
Optimal Respiratory and Sleep LLC
05.2019 - 08.2024
Manager/Head of Customer Service/Clinical Operations Program
Precision Sleep Solutions
05.2019 - 06.2021
Quality Assurance Specialist (Intern)
Cutting Edge Pipes
01.2018 - 01.2020
Interim Director/Population Health Manager/Lead Underwriter
Vitalis Health
03.2017 - 05.2019
Director Operations
Royal Kid's Palace
01.1994 - 12.2016
Associate of Science - Respiratory Care and Therapy
San Jacinto College
Bachelor of Science - Health Prevention and Wellness
Rasmussen College
Master of Science - Public Health and Health Education
Columbia Southern University