Shilique Smith
Summary
With over 7 years of experience in the insurance and fraud detection industry, I have demonstrated exceptional proficiency in managing claims, detecting fraudulent activities, and delivering outstanding customer service. My expertise includes insurance fraud expertise, data entry, documentation, reporting, and verbal and written communication skills. I am known for my meticulous attention to detail, ensuring accuracy in benefit determinations and fraud detection, which has significantly enhanced operational efficiency and client trust.
Overview
9
9
years of professional experience
Work History
Patient Access Representative
VCU Health System
07.2024 - Current
- Coordinated patient registration processes to ensure accurate data collection and compliance with healthcare regulations.
- Facilitated insurance verification and prior authorization, enhancing patient access and reducing delays in treatment.
- Streamlined appointment scheduling systems, improving patient flow and optimizing resource allocation for clinical departments.
- Mentored new staff on operational procedures and best practices, fostering a collaborative work environment.
- Ensured compliance with HIPAA regulations to maintain confidentiality of sensitive patient information during all interactions.
- Adapted quickly to changing demands within the healthcare environment, demonstrating flexibility and a strong commitment to quality patient care.
- Managed challenging situations effectively by remaining calm under pressure while resolving conflicts or addressing dissatisfied patients professionally.
- Facilitated smooth billing processes by verifying insurance eligibility, obtaining authorizations, and accurately entering claim details into the system.
Virtual Claims Processor
Maximus Call Center
01.2021 - 07.2024
- Processed insurance claims efficiently, ensuring compliance with company policies and regulations.
- Reviewed documentation for accuracy, identifying discrepancies and resolving issues proactively.
- Trained new processors on system usage and best practices, fostering a cohesive team environment.
- Analyzed claim trends to identify areas for operational improvement and implemented corrective actions.
- Managed high-volume claims processing while maintaining exceptional attention to detail and quality standards.
- Reviewed and analyzed claims to ensure accuracy, completeness, and compliance with company policies.
- Reviewed applications and supporting documents to verify claims eligibility and accuracy.
- Managed workload and priorities to meet claims processing meet deadlines.
Claims Adjuster
Randstad
03.2020 - 12.2021
- Evaluated insurance claims to determine validity, ensuring compliance with policy guidelines.
- Collaborated with clients and stakeholders to gather necessary documentation for claims processing.
- Maintained compliance with state regulatory requirements through meticulous documentation and adherence to company policies.
- Prepared summaries of damage, payments, and policy coverage.
- Reviewed police reports, medical treatment records, and physical property damage to determine extent of liability.
- Evaluated coverage accurately by interpreting complex insurance policies and applying them to specific claim scenarios.
- Reviewed and revised company policies related to claims adjusting, aligning with industry standards and regulations.
- Developed streamlined processes that improved claims handling efficiency and reduced turnaround time.
Fraud Analyst
DailyPay
04.2019 - 03.2020
- Analyzed transaction data to identify and mitigate fraudulent activities, enhancing overall security measures.
- Collaborated with cross-functional teams to develop strategies for reducing fraud risk and improving customer trust.
- Analyzed large amounts of data to find patterns of fraud and anomalies.
- Maintained up-to-date knowledge of regulations related to fraud prevention, ensuring compliance with relevant laws and guidelines.
- Enhanced fraud detection capabilities by implementing advanced analytics and machine learning algorithms.
- Enabled faster resolution of fraud claims by automating parts of investigation process.
- Increased customer trust and confidence by effectively communicating fraud investigation outcomes.
- Reviewed transactions and receipts to identify any suspicious activity.
Processing Specialist
Conduent
05.2016 - 03.2019
- Streamlined processing workflows to enhance operational efficiency and accuracy.
- Mentored junior staff on best practices in document management and data entry.
- Utilized advanced data management systems to optimize information retrieval and reporting processes.
- Completed coverage by delivering policies, planning future follow-up conversations and evaluating needs.
- Maintained high levels of accuracy throughout daily tasks, resulting in a strong track record of minimal errors or rework required.
- Demonstrated adaptability by quickly learning new software programs as needed for various processing assignments.
- Developed comprehensive knowledge of industry-specific regulations, ensuring all processed materials adhered to the relevant guidelines.
- Created spreadsheets for more efficient recordkeeping.
Education
High School Diploma -
Huguenot High School
Richmond, VA06-2017
Skills
- Customer service
- Multitasking and organization
- Registration and admissions
- Medical terminology
- Healthcare systems navigation
- Problem-solving
- Conflict resolution
- Team leadership
- Claims investigation
- Fraud prevention
- Data analysis
Accomplishments
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Resolved product issue through consumer testing.
- Supervised team of over 30+ staff members.
- Customer Relations - Earned highest marks for customer satisfaction, company-wide.
- Customer Follow-up - Ensured that customers were satisfied with company products and services by doing purchase follow-up calls.
- Monetary Transactions - Handled cash, check, credit and automatic debit card transactions with 100% accuracy.
- Conflict Resolution - Responsible for handling customer account inquiries, accurately providing information to ensure resolution of product/service complaints and customer satisfaction.
- Telephone Service - Professionally processed 80+ calls per day, providing information and service to ensure customer satisfaction.
Timeline
Patient Access Representative
VCU Health System
07.2024 - Current
Virtual Claims Processor
Maximus Call Center
01.2021 - 07.2024
Claims Adjuster
Randstad
03.2020 - 12.2021
Fraud Analyst
DailyPay
04.2019 - 03.2020
Processing Specialist
Conduent
05.2016 - 03.2019
High School Diploma -
Huguenot High School
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