Nina Lema
Schenectady,NY
Summary
Analytical Claims Examiner known for high productivity and efficient task completion. Possess specialized skills in claim investigation, policy interpretation, and dispute resolution. Excel at communication, problem-solving, and decision-making to facilitate fair and timely claim settlements.
Overview
18
18
years of professional experience
Work History
Claims Examiner
Prudential
Schenectady, NY
05.2022 - Current
- Supervised independent adjusters to promote adherence to guidelines.
- Interpreted policy language contained within contracts between providers and payers.
- Investigated discrepancies in claims and resolved issues with customers via telephone or written correspondence.
- Drafted statement of loss to summarize damages, payments and underlying policy coverage.
- Verified liability extent with reviews of police reports, medical treatment histories and other records.
- Tracked progress of pending cases through manual follow-up or automated systems.
- Researched and followed up on denied insurance claims.
- Provided guidance to other staff members regarding claim processing rules and regulations.
- Explained loss coverage, assisted policyholders with itemizing damages and coordinated alternative living arrangements.
- Documented claim actions and decisions thoroughly for audit purposes.
- Investigated potentially fraudulent claims with focus on thoroughness, quality, and cost control.
- Reviewed claims to ensure accuracy, resulting in multiple claim reductions.
- Coordinated with medical experts to evaluate the extent of injury claims.
- Conducted daily reviews on claim files and verified sending of status letters to policyholders.
- Processed appeals from denied claims according to established procedures while ensuring compliance with applicable laws and regulations.
Care Specialist Supervisor
EmblemHealth
Albany, NY
10.2020 - 05.2022
- Led team meetings to update on goals, share best practices, and discuss improvements.
- Answered, screened and processed high volume of calls daily with call management system and web-based communications.
- Trained and supervised new employees to promote overall team productivity and consistent service.
- Coordinated staff schedules to ensure optimal coverage during peak hours.
- Facilitated training sessions for new hires and ongoing development for existing staff.
- Monitored calls for quality assurance purposes.
- Worked with training team to maintain frontline agent and tier I and II agent product support and certification training initiatives.
- Prepared reports on team performance, customer feedback, and operational metrics for senior management.
- Established ambitious goals for employees to promote achievement and surpass business targets.
- Reviewed customer complaints to determine appropriate methods for resolution.
- Performed root cause analysis to identify opportunities for improvement in operations.
- Implemented strategies to enhance customer satisfaction and loyalty.
- Coached staff on strategies to enhance performance and improve customer relations.
Medical Secretary Supervisor
CARDIOLOGY ASSOCIATE
Schenectady County, NY
01.2019 - 05.2020
- Ensures physician productivity by maintaining calendars; scheduling patient appointments; physician consultations; professional meetings, conferences; teleconferences, and travel
- Provided support and preformed regular QA reviews for client intake, registration and scheduling functions
- Provides historical reference by developing and utilizing filing and retrieval systems; maintaining patient records; recording meeting discussions
- Generates revenues by completing direct patient and third-party billing; monitoring accounts receivables; initiating collection calls and reminders
- Secures information by completing database back-ups
- Maintains patient confidence and protects operations by keeping information confidential
- Maintains office supplies inventory by checking stock; anticipating needs; placing and expediting orders; verifying receipt
- Keeps office equipment operating by following operating instructions; troubleshooting breakdowns; maintaining supplies; performing preventive maintenance; calling for repairs
- Maintains quality results by following and enforcing standards
- Serves and protects the health care community by adhering to professional standards, hospital policies and procedures, federal, state, and local requirements, and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards
- Updates job knowledge by participating in educational opportunities; reading professional publications
- Enhances physician office reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments
- Processed and prepared patient billing and insurance claims.
- Adhered to HIPAA requirements to safeguard patient confidentiality.
- Managed daily calendars for multiple providers, setting up appointments as needed.
- Transcribed medical dictation and prepared referral letters.
- Updated group medical records and technical library to promote smooth office operations.
- Monitored patient messages sent via email or phone message system and responded accordingly.
- Performed data entry tasks related to patient information into various databases.
- Compiled and coded patient information or data in appropriate computer system.
- Prepared reports, invoices, letters, or medical records using word processing, spreadsheet, or other software applications.
- Applied knowledge of medical terminology and insurance processes to support office administration productivity.
Office Manager
Albany Family Medicine
01.2017 - 12.2018
- Assisted in developing budgets for departmental expenses.
- Planned and delivered training sessions to improve employee effectiveness and address areas of weakness.
- Managed office budget to handle inventory, postage and vendor services.
- Developed effective communication strategies between departments within the organization.
- Delegated work to staff, setting priorities and goals.
- Coded and entered daily invoices with in-house accounting software.
- Analyzed business performance data and forecasted business results for upper management.
- Organized company events including holiday parties, team building activities .
- Held regular one-on-one meetings with employees to review performance and priorities and provide feedback.
- Trained and mentored administrative staff members in company policies, daily task execution and industry best practices.
- Implemented and maintained company protocols to facilitate smooth daily activities.
- Planned and led team meetings to review business results and communicate new and ongoing priorities.
- Provided training to new hires on office policies and procedures.
- Implemented quality control measures to uphold company standards.
- Interviewed prospective employees and provided input to HR on hiring decisions.
- Provided leadership, insight and mentoring to newly hired employees to supply knowledge of various company programs.
- Maintained impeccable office organization to support efficiency, professionalism and performance objectives.
- Administered payroll and maintained proper documentation of employee personnel.
Medical Secretary
The Bone & Joint Center
03.2016 - 01.2017
- Transcribed medical dictation and prepared referral letters.
- Documented and responded to incoming correspondences to address questions.
- Managed daily calendars for multiple providers, setting up appointments as needed.
- Managed physician correspondence and drafted medical reports.
- Scheduled and confirmed patient appointments, surgeries, and medical consultations.
- Prepared patient charts for physicians prior to appointments, including updating existing information.
- Conducted follow-up calls to patients for appointment reminders and care instructions.
- Transcribed recorded practitioners' diagnoses and recommendations into medical records.
- Planned and delivered training sessions to improve employee effectiveness and address areas of weakness.
- Provided administrative support to management team including preparing reports and presentations.
Call Center Supervisor
Value Options
Latham, New York
06.2014 - 10.2015
- Led team meetings to update on goals, share best practices, and discuss improvements.
- Answered, screened and processed high volume of calls daily with call management system and web-based communications.
- Conducted testing of software and systems to ensure quality and reliability.
- Conducted regular performance reviews and provided constructive feedback to team members.
- Coordinated with IT department to troubleshoot and resolve technical issues impacting call center operations.
- Maintained strong call control and quickly worked through scripts to address problems.
- Facilitated communication between departments to resolve problems quickly.
- Delivered constructive call process feedback.
- Documented changes made within the department as part of continuous improvement efforts.
- Reviewed daily reports on call volume, sales, abandoned calls and other statistics.
- Directed and supervised staff performance.
- Created incentives for employees who achieved high performance standards.
- Mentored newly hired employees by explaining tactics for building sales pipelines.
- Provided guidance, training, coaching and mentoring to call center team members.
- Participated in the recruitment and selection process for new team members.
- Handled escalated customer service concerns to preserve customer satisfaction and maintain long-term business relationships.
Sales Supervisor
Time Warner Cable
01.2007 - 06.2013
- Established clear expectations for quality control processes among staff members.
- Developed incentive programs for top performing sales representatives.
- Created monthly reports on regional sales performance and presented to upper management.
- Led employee performance evaluations and rewarded top performers to retain quality personnel.
- Managed sales personnel, setting performance goals and strategies for attaining objectives.
- Supported sales team members to drive growth and development.
- Raised profits by setting ambitious sales goals for employees, encouraging sales staff, prioritizing customer service, and resolving customer issues.
- Promoted key products and features to customers to generate interest and drive revenue growth.
- Exceeded targeted goals and quotas through upselling and strategic customer cultivation.
- Recruited and trained new employees to meet job requirements.
- Ensured compliance with company policies and procedures related to sales operations.
- Directed and supervised staff performance.
- Provided leadership, insight and mentoring to newly hired employees to supply knowledge of various company programs.
- Coached staff on strategies to enhance performance and improve customer relations.
Education
Associate of Arts - Paralegal Studies
Schenectady County Community Collage
Schenectady County, NYSkills
- Coverage analysis
- Microsoft Office Suite
- Investigative skills
- Disability claims process
- Healthcare procedures
- Verbal communication
- Liability and coverage
- Claims processing
- Policy investigations
- Fraud identification
- Team Training
- Professional demeanor
- Verbal and written communication
- Problem-solving abilities
- Interview claimants
- Organizational skills
- Decision-making
- Insurance Law Understanding
- Task prioritization
- Attention to detail
Timeline
Claims Examiner
Prudential
05.2022 - Current
Care Specialist Supervisor
EmblemHealth
10.2020 - 05.2022
Medical Secretary Supervisor
CARDIOLOGY ASSOCIATE
01.2019 - 05.2020
Office Manager
Albany Family Medicine
01.2017 - 12.2018
Medical Secretary
The Bone & Joint Center
03.2016 - 01.2017
Call Center Supervisor
Value Options
06.2014 - 10.2015
Sales Supervisor
Time Warner Cable
01.2007 - 06.2013
Associate of Arts - Paralegal Studies
Schenectady County Community Collage