MELISSA KINGSBERRY
Decatur,GA
Summary
Dedicated and analytical professional with extensive experience in health insurance claims auditing, client relations and compliance. Proficient in conducting compliance reviews, analyzing trends and collaborating with departments to implement corrective actions. Strong communicator with a proven track record of improving claims management and ensuring regulatory adherence.
Overview
8
8
years of professional experience
Work History
Specific Claims Auditor
Tokio Marine
04.2023 - Current
- Conduct compliance reviews of health insurance claims, ensuring adherence to regulatory and internal guidelines
- Audit submitted claim documents to verify data sufficiency, correct benefit payments, and policy compliance
- Collaborate with Third-party administrators (TPAs) and clients to resolve claim processing issues and develop corrective action plans
- Set and adjust claims reserves, authorizing checks for liability amounts and providing explanations for uncovered amounts
- Refer large-dollar claims and trigger diagnoses to preliminary claims and case management departments
- Prepare and present detailed reports on audit findings to managemen
Commercial Insurance Assistant & Commercial Claims Adjuster
Liberty Mutual
10.2021 - 01.2023
- Managed correspondence and clerical processing of accounts, including applications, pre-renewal data collections, and agency management system input
- Provided account managers, producers, and marketing loss reports
- Maintained cancellation and reinstatement requests for commercial accounts
- Conducted investigations of claims, securing evidence, and determining liability, compensability, and damages
- Handled general liability and low-complexity bodily injury claims, negotiating settlements within authority limits
- Assessed policy coverage for claims, established reserve requirements, and maintained ownership throughout the claim's duration
Claims Associate
State Farm Insurance
04.2017 - 10.2021
- Maintained strong product and service knowledge to assist customers with claims process inquiries
- Recorded customer information to verify identity and reduce potential fraud
- Utilized critical thinking and decision-making skills to determine liability for property damage and auto claims
- Issued payments for invoices while ensuring compliance with jurisdictional requirements
- Managed 50-80 incoming calls per day from customers.'
Education
DeVry University - Healthcare Administration
DeVry University
Decatur, GA12.2026
High School Diploma -
D.M Therrell High School
Atlanta, GA05.2006
Skills
- Audit of Claims Processes
- Compliance Management
- Data analysis
- Evaluation of Corrective Action Effectiveness
- Client Relations
- Communication skills
- Claims investigation
- Regulatory compliance
- Claims auditing
- Attention to detail
- Insurance policy evaluation
- Problem solving
- Customer service
- Documentation review
- Critical thinking
Timeline
Specific Claims Auditor
Tokio Marine
04.2023 - Current
Commercial Insurance Assistant & Commercial Claims Adjuster
Liberty Mutual
10.2021 - 01.2023
Claims Associate
State Farm Insurance
04.2017 - 10.2021
High School Diploma -
D.M Therrell High School
DeVry University - Healthcare Administration
DeVry University
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