Summary
Overview
Work History
Education
Skills
Timeline
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Shenika Rivers

Decatur,GA

Summary

Seasoned Insurance Specialist, Customer Service Representative with excellent planning and problem solving abilities. Offering 8 year of experience and a willingness to take on any challenge. Organized, driven and adaptable professional with successful history managing high caseloads in fast-paced environments.

Overview

7
7
years of professional experience

Work History

Insurance Claims Specialist

Allstate
Tucker, GA
04.2023 - Current
  • Processed requests for additional documentation from customers in a timely manner.
  • Calculated benefit payments based on policy terms, coverage limits, and applicable regulations.
  • Assisted customers in filing new insurance claims and provided status updates on existing ones.
  • Maintained detailed records of all claim activities including correspondence, decisions, payments.
  • Reviewed customer insurance claims to ensure accuracy and completeness of information.
  • Reviewed denied claims for errors or omissions before finalizing decision notices.
  • Analyzed claim records, policy provisions, and other relevant documents to determine validity of claims.
  • Provided guidance to customers regarding their rights and obligations under the insurance policies.
  • Participated in training sessions conducted by insurers on new products and services.
  • Determined liability, compensability, and benefits due on each claim.
  • Negotiated settlements between claimants and insurers when necessary to resolve disputes quickly.
  • Resolved customer complaints related to insurance claim processing.
  • Supported efficient handling of complex claims and followed up on open, denied, or suspended claims to complete required line items.
  • Ensured compliance with state laws governing insurance practices as well as company policies and procedures.

Member Service Representative

Florida Blue - Blue Cross Blue Shield Of Florida
Jacksonville, FL
11.2021 - 05.2022
  • Provided support to members regarding account inquiries, processing transactions, and resolving issues.
  • Answered incoming calls regarding membership benefits and services.
  • Enhanced member relationships by providing excellent service during each interaction.
  • Performed cash handling duties such as deposits and withdrawals for members' accounts.
  • Updated patient files in accordance with company policy and procedure guidelines.
  • Adhered to HIPAA regulations when handling confidential patient information.
  • Verified patient demographic information in order to ensure accuracy of data entry.
  • Utilized active listening and communication skills to address customer inquiries and escalate issues to supervisor.
  • Scheduled appointments for patients using the electronic health records system.
  • Compiled reports on patient visits for management review as needed.
  • Accessed patient information through various software applications, maintaining strict confidentiality to remain compliant with HIPAA regulations.
  • Obtained insurance verification and authorization to submit financial clearance of patient accounts.
  • Scheduled patient appointments and procedures.
  • Registered patients by verifying records to update computer system and patient charts.
  • Utilized MS Office and Excel to analyze data and create spreadsheets.
  • Completed timely changes and updates to schedules in central scheduling system.

Insurance Verification Specialist

Florida Health Department
Jacksonville, FL
05.2017 - 08.2021
  • Verified that patients had proper insurance coverage prior to procedures or appointment scheduling.
  • Updated patient and insurance data and input changes into company computer system.
  • Verified patient eligibility for insurance coverage by contacting insurance carriers and obtaining the necessary authorization numbers.
  • Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.
  • Communicated with insurance carrier, patient and third party or employer to verify patient insurance benefits.
  • Entered data in EMR database to record payer, authorization requirements and coverage limitations.
  • Navigated through multiple online systems to obtain documentation.
  • Accessed third-party insurance databases to identify coverage of benefits.
  • Maintained accurate documentation on all pre-authorization requests, denials and appeals.
  • Developed a working knowledge of insurance plans, including Medicare and Medicaid regulations and requirements.
  • Contacted patients to confirm demographic information and communicate financial responsibilities.
  • Checked documentation for appropriate coding, catching errors and making revisions.
  • Identified discrepancies in patient's insurance coverage or benefits, ensuring accuracy of data entered into system.
  • Reviewed medical records to ensure accuracy of required information needed for pre-authorization requests.
  • Retained strong medical terminology understanding in effort to better comprehend procedures.
  • Evaluated policies and procedures related to Insurance Verification activities.
  • Interpreted Explanation of Benefits statements from various insurers and communicated relevant information with other departments as needed.
  • Contacted patients to arrange payment arrangements for deductible and out-of-pocket liability.
  • Determined estimated self-pay portion by calculating charges, co-insurance and deductibles.
  • Participated in training sessions on new software programs used for verification purposes.

Education

High School Diploma -

First Coast High School
Jacksonville, FL
06-2013

Skills

  • Policy Interpretation
  • Coverage Assessments
  • Documentation Review
  • Claims Processing
  • Verbal Communication
  • Microsoft Office
  • Customer Service
  • Data Entry

Timeline

Insurance Claims Specialist

Allstate
04.2023 - Current

Member Service Representative

Florida Blue - Blue Cross Blue Shield Of Florida
11.2021 - 05.2022

Insurance Verification Specialist

Florida Health Department
05.2017 - 08.2021

High School Diploma -

First Coast High School

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Shenika Rivers