Melissa Richter
Bonduel,WI
Summary
Claims and Investigations Professional with extensive experience in insurance claims review, eligibility verification and documentation analysis, supported by formal medical coding education. Skilled in reviewing medical records and claims data to identify discrepancies, ensure regulatory and reimbursement compliance and support investigative decision-making. Proven ability to analyze complex information across multiple systems, document findings accurately and work independently in fast-paced, compliance-driven environments. Strong background in claims investigation, fraud detection support, HIPAA adherence, and cross-functional collaboration within large healthcare organizations.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Enrollment & Eligibility Team Lead
UnitedHealthcare
01.2024 - Current
- Lead and mentor team members in eligibility and enrollment research, ensuring adherence to regulatory, contractual, and internal compliance standards
- Review complex eligibility and enrollment scenarios to identify discrepancies, documentation gaps, and potential risk indicators
- Ensure accurate documentation and audit-ready records across multiple internal systems
- Support quality assurance initiatives by validating workflows, monitoring error trends and addressing root causes
- Collaborate with internal partners to resolve escalated cases involving complex data and compliance concerns
Enrollment & Eligibility Representative
UnitedHealthcare
04.2022 - 01.2024
- Researched and verified member and group eligibility using multiple claims and enrollment systems
- Analyzed transactional data to identify inconsistencies, discrepancies, and missing documentation
- Investigated eligibility-related issues impacting claims processing and reimbursement
- Documented findings clearly to support resolution, compliance, and downstream review
- Collaborated with internal partners and brokers to obtain and validate required documentation
Rental Representative
Ameriprise Auto & Home Insurance
08.2021 - 04.2022
- Manage rental and repair process.
- Negotiated with repair facilities.
- Utilized problem-solving techniques to resolve customer inquiries in an efficient and timely manner.
Auto Claims Adjuster
Ameriprise Auto & Home Insurance
10.2015 - 08.2021
- Conducted in-depth claims investigations by reviewing documentation, statements, and supporting records
- Identified incorrect, inconsistent, or potentially fraudulent documentation through detailed analysis
- Assessed liability and coverage compliance based on policy terms and regulatory requirements
- Documented investigative findings accurately to support claim outcomes and audit requirements
- Worked independently on complex cases requiring critical thinking and sound judgment
Claims Service Representative
Ameriprise Auto & Home Insurance
04.2014 - 10.2015
- Provided support for claims documentation and benefit explanations.
- Ensured complete and accurate recordkeeping.
Education
Medical Coding Specialist Program -
Northeast Wisconsin Technical College
05.2026
Surgical Technologist Program - undefined
Northeast Wisconsin Technical College
10.2013
High School Diploma - undefined
Bonduel High School
05.2012
Skills
- Claims Research & Investigation
- Medical Record Review & Fact Gathering
- Regulatory, Reimbursement & Contract Compliance
- Fraud, Waste & Abuse Awareness
- Data Analysis & Discrepancy Identification
- Investigation Documentation & Case Tracking
- HIPAA & PHI Compliance
- Independent, Self-Directed Work
- Microsoft Excel (sorting, filtering, data review
Certification
CCA – Certified Coding Associate, AHIMA
Timeline
Enrollment & Eligibility Team Lead
UnitedHealthcare
01.2024 - Current
Enrollment & Eligibility Representative
UnitedHealthcare
04.2022 - 01.2024
Rental Representative
Ameriprise Auto & Home Insurance
08.2021 - 04.2022
Auto Claims Adjuster
Ameriprise Auto & Home Insurance
10.2015 - 08.2021
Claims Service Representative
Ameriprise Auto & Home Insurance
04.2014 - 10.2015
Surgical Technologist Program - undefined
Northeast Wisconsin Technical College
High School Diploma - undefined
Bonduel High School
Medical Coding Specialist Program -
Northeast Wisconsin Technical College