Sandra Kirby

Analyzed and resolved complex claims involving liability determination, coverage interpretation, and damages evaluation in accordance with policy provisions and regulatory requirements.

• Conducted in‑depth investigations by reviewing documentation, recorded statements, estimates, medical records, and contractual language to ensure accurate and fair claim outcomes.
• Applied advanced analytical skills to identify coverage issues, assess financial exposure, and recommend appropriate settlement strategies within designated authority levels.
• Negotiated settlements with claimants, attorneys, medical providers, and vendors to achieve timely resolutions while minimizing company risk and expense.
• Ensured compliance with state regulations, internal guidelines, and audit standards through meticulous documentation and claim file management.
• Collaborated with legal counsel, underwriting, subrogation, and management teams on high‑severity or sensitive claims to support informed decision‑making.
• Served as a subject matter resource to junior analysts by providing guidance on policy interpretation, best practices, and complex claim scenarios.
• Consistently met or exceeded performance metrics related to cycle time, customer satisfaction, and quality assurance standards

Reviewed, analyzed, and adjusted insurance claims to ensure accuracy, compliance, and alignment with policy provisions, contractual requirements, and regulatory standards.

• Evaluated claim documentation, financial data, estimates, and supporting records to determine appropriate adjustments and payment accuracy.
• Identified discrepancies, overpayments, underpayments, and coverage issues, recommending corrective actions to mitigate financial risk.
• Applied analytical judgment to assess claim complexity, exposure, and resolution strategies while adhering to established authority levels.
• Collaborated with claims adjusters, analysts, supervisors, and external partners to resolve disputed or escalated adjustments efficiently.
• Maintained detailed documentation of findings, adjustments, and recommendations to support audits, quality reviews, and compliance requirements.
• Tracked adjustment trends and patterns, contributing insights to process improvement and loss prevention initiatives.
• Consistently met productivity, accuracy, and quality benchmarks in a high‑volume, deadline‑driven environment.

• Edits for Clinical Waste & Abuse edits
• Manage QET CCR Error Correction Reports, Identify quality issues or trends through data analysis.
• SME for DRG Coders on Claim payments, DRG Contracts, Troubleshoot claim payment errors.
• Assist CCR Processors with various QET issues.

• Mastered all roles within Team of High Dollar/Complex Claim Clinical Scrub
• Assisted on review and implementation of original CCR SOP's
• Lead on Escalated Email Box
• Created checklist for current scrub team.
• Back up to Quality Intake tool.
• Conducted OJT audits for new team members, assisted peers with day to day
• Escalated job functions. Team Training on various apps. Lead Team huddles as needed.
• Assist Matrix partners with various questions daily.

Reviewed claims prior to payment to identify errors, inconsistencies, or discrepancies related to coverage, pricing, coding, policy provisions, and system data.

• Analyzed claim details, financial calculations, contracts, and supporting documentation to ensure payment accuracy before release.
• Corrected pre‑payment errors by applying policy guidelines, business rules, and regulatory requirements to reduce financial leakage and rework.
• Collaborated with claims adjusters, analysts, and processing teams to resolve identified issues and ensure timely, accurate claim resolution.
• Utilized analytical skills to assess root causes of recurring errors and recommend corrective or preventive actions.
• Maintained detailed documentation of corrections, findings, and decisions to support audits, quality assurance, and compliance reviews.
• Monitored pre‑pay trends and error patterns, providing insights to improve workflows, training, and system enhancements.
• Consistently met productivity, accuracy, and quality benchmarks in a fast‑paced, deadline‑driven environment.