Telisha Simons
San Antonio
Summary
Dynamic Claims Adjuster with a proven track record at USAA, excelling in claims investigation and critical thinking. Recognized for enhancing claims processing efficiency and fostering collaboration among teams. Highly motivated to deliver exceptional service while maintaining compliance and accuracy in documentation, ensuring client satisfaction throughout the claims journey.
Wellness project coordinator with experience in claims processing and documentation management. Reviewed and assessed insurance claims for accuracy, collaborating with team members to streamline procedures and improve efficiency. Conducted thorough investigations into complex claims, ensuring compliance with regulatory requirements while maintaining confidentiality of sensitive information. Developed training materials and reports to identify trends, contributing to proactive problem-solving initiatives within the team.
Overview
5
5
years of professional experience
Work History
Claims Adjuster
USAA
01.2023 - Current
- Reviewed and assessed insurance claims for accuracy and completeness.
- Assisted in gathering necessary documentation to support claims processing.
- Communicated with clients to explain the claims process and address inquiries.
- Collaborated with team members to streamline claims handling procedures.
- Conducted research on policy coverage to determine claim validity.
- Examined claims forms and other records to determine insurance coverage.
- Maintained compliance with state regulatory requirements through meticulous documentation and adherence to company policies.
- Conducted thorough investigations of complex insurance claims, gathering evidence and analyzing relevant documentation.
- Prepared summaries of damage, payments, and policy coverage.
- Contributed to a positive work environment through active participation in team meetings and collaborating on cross-functional projects.
- Reviewed police reports, medical treatment records, and physical property damage to determine extent of liability.
- Conducted comprehensive interviews of witnesses and claimants to gather facts and information.
- Facilitated smooth transitions for policyholders during the claim process by liaising between various departments, ensuring all parties were informed and engaged.
Claims Coordinator
United Healthcare Group
12.2022 - 12.2022
- Processed and reviewed insurance claims for accuracy and compliance with company policies.
- Coordinated communication between clients, providers, and internal teams to resolve claim issues promptly.
- Utilized claims management software to track and manage claim submissions efficiently.
- Assisted in developing training materials for new team members on claims processing procedures.
- Developed comprehensive reports outlining trends in common claim issues which allowed for proactive problem-solving initiatives.
- Conducted detailed investigations into complex claims cases, gathering necessary information to reach accurate conclusions and determine appropriate actions.
- Prepared claims summaries, loss stratification reports and mod analysis reports.
- Maintained strict adherence to confidentiality guidelines, ensuring sensitive client information was securely handled and protected at all times.
- Monitored pending claims closely to identify potential issues or delays in processing promptly addressing them before escalation occurred.
- Delegated tasks to administrative support staff to organize and improve office efficiency.
- Improved office operations by automating client correspondence, record tracking and data communications.
- Implemented project management techniques to overcome obstacles and increase team productivity.
- Organized meetings for executives and coordinated availability of conference rooms for participants.
- Organized spaces, materials and catering support for internal and client-focused meetings.
- Built highly-efficient administrative team through ongoing coaching and professional development opportunities.
- Developed internal requirements and standards to minimize regulatory risks and liability across programs.
- Conducted ongoing reviews of program financial systems to assess cost control measures.
Medical Claims Coordinator
University Health Science Center
04.2021 - 11.2022
- Processed medical claims using electronic health record systems to ensure timely reimbursement.
- Reviewed and verified claim accuracy, resolving discrepancies in documentation promptly.
- Collaborated with healthcare providers to gather necessary information for claims submission.
- Maintained up-to-date knowledge of insurance regulations and billing procedures.
- Assisted in training new staff on claims processing workflows and compliance standards.
- Coordinated communication between patients and insurers to facilitate resolution of billing inquiries.
- Provided exceptional customer service to patients during the claims process, addressing concerns promptly while remaining professional at all times.
- Optimized medical claims processing time by proactively identifying potential setbacks or delays before they occurred.
- Assisted healthcare providers with understanding insurance company policies, leading to improved claim submission practices and reduced errors.
- Improved patient satisfaction with effective communication of claim statuses and updates throughout the process.
- Developed strong working relationships with insurance company representatives, fostering collaboration and cooperation in claims resolution.
Education
Bachelor of Science - Medical Claims Billing And Coding
Nova Southeastern University
Davie, FLSkills
- Critical thinking
- Claims investigation
- Active listening
- Highly motivated
- Claims assessment
- Documentation management
- Client communication
Timeline
Claims Adjuster
USAA
01.2023 - Current
Claims Coordinator
United Healthcare Group
12.2022 - 12.2022
Medical Claims Coordinator
University Health Science Center
04.2021 - 11.2022
Bachelor of Science - Medical Claims Billing And Coding
Nova Southeastern University