Raquel Sims
ROCHESTER
Summary
Detail-oriented Senior Claims Specialist with expertise in medical claims processing, billing, coding support, and revenue cycle management. Specializes in resolving complex claims issues, interpreting insurance policies, and ensuring HIPAA compliance. Experienced in collaborating with providers and insurance carriers to enhance accuracy and operational efficiency. Aiming to leverage analytical and communication skills to drive improvements in customer satisfaction.
Overview
5
5
years of professional experience
1
1
Certification
Work History
Senior Claims Specialist
Inspira Financial
ROCHESTER
06.2024 - 05.2026
- Processed high-volume medical claims while maintaining exceptional accuracy and productivity.
- Investigated and resolved complex claim discrepancies, denials, and payment issues.
- Reviewed medical documentation to ensure compliance with insurance policies and healthcare regulations.
- Coordinated with providers, hospitals, and insurance carriers to expedite claims resolution.
- Educated members and providers regarding claim status, benefits, and reimbursement policies.
- Maintained HIPAA compliance while handling confidential patient information.
- Assisted with escalated customer concerns and complex claims requiring senior-level review.
- Consistently exceeded quality assurance and service-level expectations.
Medical Billing & Coding Specialist
MVP Healthcare
ROCHESTER
03.2022 - 03.2024
- Submitted accurate medical claims using CPT, ICD-10, and HCPCS coding standards.
- Verified insurance eligibility and patient benefits before services.
- Followed up on unpaid claims and resolved billing issues.
- Managed claim appeals and corrected coding errors to maximize reimbursement.
- Worked closely with physicians and clinical staff to ensure documentation accuracy.
- Reduced claim denials through proactive auditing and compliance reviews.
Healthcare Customer Service Representative
Bri Benefits Resources
ROCHESTER
01.2021 - 12.2021
- Provided outstanding customer service to patients, providers, and insurance members, enhancing satisfaction and trust.
- Responded to billing questions, insurance inquiries, and claim status requests.
- Scheduled appointments and updated patient demographic information.
- Addressed and resolved customer complaints effectively, maintaining professionalism and empathy to foster positive relationships.
- Accurately documented interactions in electronic medical record systems, ensuring compliance and facilitating efficient patient care.
Education
Family Learning Education
Rochester, NYSkills
- Claims processing
- Claim resolution
- Medical coding
- HIPAA compliance
- Claims auditing
- Billing verification
- Client engagement strategies
- Attention to detail
- Problem solving
- Time management
- Team collaboration
- Effective communication
- Adaptability
Certification
- Certified Professional Coder (CPC) – AAPC
- HIPPA Certified
Timeline
Senior Claims Specialist
Inspira Financial
06.2024 - 05.2026
Medical Billing & Coding Specialist
MVP Healthcare
03.2022 - 03.2024
Healthcare Customer Service Representative
Bri Benefits Resources
01.2021 - 12.2021
Family Learning Education