Taylor Caguias
Waynesboro,PA
Summary
Thorough Claims Resolution Specialist that is skilled handling basic and complex claims with accuracy and efficiency. I have good communication, organizational and problem-solving abilities. I am committed to maintaining customer satisfaction and contributing to company success. My long term and current goals are to grow within UnitedHealth Group as a whole and to expand my knowledge and capabilities within the company.
Overview
10
10
years of professional experience
Work History
Claims Resolution Specialist
UnitedHealth Group
08.2015 - Current
- Achieved high customer satisfaction ratings by providing prompt, empathetic, and accurate resolutions to claims.
- Collaborated with various departments for comprehensive claim evaluations, improving overall outcomes.
- Increased accuracy in claims assessment through meticulous record-keeping and organized documentation.
- Ensured compliance with industry regulations and company policies by staying up-to-date on relevant guidelines.
- Contributed to team success by consistently meeting or exceeding individual performance metrics for claim resolution.
- Continuously improved personal knowledge of industry best practices through attending workshops, conferences, and webinars.
- Participated in quality assurance initiatives to continuously improve the effectiveness of the claims resolution process.
- Processed adjustments and posted refunds.
- Followed up with customers on unresolved issues.
- Understood requirements for disputes, gathered evidence to support claims and prepared customer cases to handle appeals.
- Monitored compliance with regulations and industry best practices to promote fair and proper treatment for insured customers.
- Responded to inquiries by answering questions, providing information and directing customers to appropriate resources.
- Provided advice to customers regarding claims, rights and insurance processes to prevent disputes.
- Managed team reports to ensure prompt handling of customer issues in a timely manner.
- Trained/Managed agents/employees on specific claim processes and projects.
Member Services Health Advisor & Benefit Advocate
UnitedHealth Group
03.2014 - 08.2015
- Improved patient satisfaction by identifying and resolving healthcare concerns through comprehensive research and communication.
- Streamlined the insurance claims process for clients by navigating complex healthcare policies and advocating for coverage of necessary treatments.
- Coordinated with medical professionals to ensure timely access to appropriate care for patients in need of specialized services.
- Promoted patient autonomy by empowering them with knowledge and resources to make informed decisions about their healthcare.
- Advocated for affordable prescription medication access, resulting in cost savings for clients without compromising treatment efficacy.
- Maintained full and current understanding of available plans, products and services.
- Provided information such as copay and premium details, pre-approval procedures and available products.
- Handled more than 50 daily inbound calls from health plan customers.
- Resolved problems related to benefits, eligibility and claims.
- Helped members navigate enrollment process and choose appropriate options.
Education
High School Diploma -
Waynesboro Area Senior High School
Waynesboro, PA06.2010
Skills
- Claim analysis and processing
- Billing Procedures
- Policy Coverage Understanding
- Problem Solving
- Organizational Skills
- Customer Service
- Insurance Terminology
- Decision Making
- Computer Literacy
- Analytical Thinking
- Time Management
- Regulatory Compliance
- Healthcare Common Procedures Coding System (HCPCS)
- Adaptability and Flexibility
- Staff Management
Timeline
Claims Resolution Specialist
UnitedHealth Group
08.2015 - Current
Member Services Health Advisor & Benefit Advocate
UnitedHealth Group
03.2014 - 08.2015
High School Diploma -
Waynesboro Area Senior High School
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