Rachel Cunningham

The primary function of the Claims Research Associate position is two–fold, consisting of medical claims processing and inquiry resolution. Each claim is processed according to business regulation, internal standards, and processing guidelines. Inquiries are resolved within accuracy and timeliness goals, specific to customer contract agreements. The Incumbent is responsible for reviewing claims for errors and comparing member benefits to services requested. The Incumbent will also perform an analysis of the claim and make necessary updates that may include recalculation of benefits for previously processed claims to determine the correct order of benefits for payment to be made by the applicable plan. It is also the responsibility of the incumbent to reject, redirect misrouted, or ask clarifying questions when information is incomplete or inaccurate to ensure timely processing as outlined by service level agreement goals. The Incumbent will be responsible for communicating via inquiry, email and telecommunication across multiple areas of the company to ensure customer resolution is complete.

• Developed strong relationships with clients, resulting in repeat business and positive feedback.
• Delivered exceptional customer service experiences by maintaining a positive attitude, active listening skills, and empathetic responses to customer concerns.
• Managed a high volume of inbound calls while maintaining excellent call quality standards and adhering to established procedures.
• Maintained customer satisfaction with forward-thinking strategies focused on addressing customer needs and resolving concerns.
• Provided timely assistance to customers via phone, email, and live chat channels, ensuring a high level of professionalism at all times.
• Responded to customer calls and emails to answer questions about products and services.

• Participated in the development of company-wide strategies for claims handling and resolution
• Documented all claims activity in accordance with company policies and procedures
• Researched and responded to inquiries from policyholders, brokers, and other stakeholders
• Assisted policyholders with filing and processing of claims, providing guidance and resources as needed
• Managed a portfolio of over 200 claims cases, ensuring timely resolution and accurate processing
• Maintained accurate records of all claims, ensuring compliance with regulatory requirements
• Assisted in the development of best practices for claims handling and resolution
• Developed and maintained collaborative relationships with internal and external stakeholders
• Developed and maintained relationships with internal and external stakeholders
• Monitored and managed a high-volume of claims, ensuring timely and accurate processing.