Sebastian Morales
San Antonio
Summary
Dynamic professional with extensive experience at USAA as a Non-Injury Auto Adjuster, skilled in fraud detection and claim investigation. Proven ability to resolve complex claims efficiently while maintaining meticulous documentation. Adept at effective communication and negotiation, ensuring compliance with regulatory standards and enhancing customer satisfaction.
Overview
11
11
years of professional experience
Work History
Non-Injury Auto Adjuster
USAA
San Antonio
02.2024 - Current
- Interviewed claimants, witnesses, police officers, medical professionals and other parties involved in the claim.
- Investigated and analyzed auto insurance claims to determine validity, accuracy, and coverage.
- Resolved repair cost inquiries, consulting with various appraisers for second opinions to resolve disagreements.
- Maintained up-to-date knowledge of state regulatory requirements affecting auto claims handling.
- Reviewed previous claims for possible fraud or misrepresentation of facts.
- Participated in claims review meetings, presenting cases and justifying decisions.
- Documented vehicle damage and condition by taking meticulous notes and photographs.
- Ensured compliance with internal controls, policies, and procedures in the handling of claims.
- Researched and verified insurance policy coverage.
- Maintained up-to-date knowledge of relevant legal statutes governing automobile insurance claims.
- Evaluated repair estimates for reasonableness and accuracy prior to authorizing repairs.
Senior Urgent Response Agent
Best Buy Health
San Antonio
08.2021 - 02.2024
- · Dispatch emergency support (Police, Medical, Fire) assistance for active aging citizens
- · Gather clues and cues pertaining to emergency request, and relay message to 911 Operator to ensure safety of subscribers and Fire Responders
- · Ability to maintain control, map reading abilities, knowledge of 911 dispatch procedures, excellent communication, and probing skills
- · Support Customer Service and Operator Services inbound calls related to equipment troubleshooting, billing, general inquiries, as needed
- · Create accurate logs of all communications for purpose of assuring general needs and safety of customers
- · Advocate for members, triage calls, and report crisis situations to appropriate agencies such as Adult Protective Services and Public Safety Answering Points
- · Perform initial psychological and social assessments on high volume of emergent and non-emergent contacts for assistance, which may include calls related to medical, social, and/or wellness
Prior Authorization Specialist
Christus Santa Rosa Children's Hospital
San Antonio
02.2018 - 06.2021
- Reached out to insurance carriers to obtain prior authorization for testing and procedures.
- Prepared and distributed denial letters, detailing reasons for denial and possible appeal measures.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Researched denied claims and contacted insurance companies to resolve these issues.
- Tracked referral submission during facilitation of prior authorization issuance.
- Reviewed appeals for prior authorization requests and communicated with payers to resolve issues.
- Provided prior authorization support for physicians, healthcare providers and patients in accordance with payer guidelines.
Medical Claims Processor
UMR United Healthcare
San Antonio
12.2016 - 02.2018
- Reviewed provider coding information to report services and verify correctness.
- Used administrative guidelines as resource or to answer questions when processing medical claims.
- Maintained knowledge of benefits claim processing, claims principles, medical terminology, and procedures and HIPAA regulations.
- Paid or denied medical claims based upon established claims processing criteria.
- Responded to correspondence from insurance companies.
- Managed large volume of medical claims on daily basis.
- Evaluated medical claims for accuracy and completeness and researched missing data.
- Researched and resolved complex medical claims issues to support timely processing.
- Followed up on denied claims to verify timely patient payment and resolution.
- Generated reports on medical claims processing activities and results.
- Maintained strong knowledge of basic medical terminology to better understand services and procedures.
Technical Support Representative
Volt Workforce Solutions
San Antonio
09.2014 - 11.2016
- Assisted customers in identifying issues and explained solutions to restore service and functionality.
- Collaborated with supervisors to escalate and address customer inquiries or technical issues.
- Translated complex technical issues into digestible language for non-technical users.
- Used ticketing systems to manage and process support actions and requests.
- Resolved diverse range of technical issues across multiple systems and applications for customers and end-users across various time zones.
- Documented support interactions for future reference.
- Managed high levels of call flow and responded to Apple Product technical support needs.
- Monitored systems in operation and quickly troubleshot errors.
- Researched and identified solutions to technical problems.
- Diagnosed and troubleshot hardware, software and network issues.
Education
High School Diploma -
Dillard McCollum High School
San Antonio, TXSkills
- Fraud detection
- Detail orientation
- Customer service
- Documentation skills
- Claim investigation
- Effective communication
- Time management
- Attention to detail
- Negotiation skills
Personal Information
Title: Emergency Dispatcher/ Social Care
Accomplishments
- Mentor for New Hires
- Y-Cord Champ at USAA
- Completed I-CAR Certification
- Employee Recognition
Timeline
Non-Injury Auto Adjuster
USAA
02.2024 - Current
Senior Urgent Response Agent
Best Buy Health
08.2021 - 02.2024
Prior Authorization Specialist
Christus Santa Rosa Children's Hospital
02.2018 - 06.2021
Medical Claims Processor
UMR United Healthcare
12.2016 - 02.2018
Technical Support Representative
Volt Workforce Solutions
09.2014 - 11.2016
High School Diploma -
Dillard McCollum High School
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