Derenique Burt
Bellflower,CA
Summary
Dynamic Medical Insurance Advisor with United Healthcare, skilled in medical claims review and processing. Proven track record in achieving high productivity while maintaining exceptional accuracy. Adept at resolving complex claims issues through effective communication and problem-solving. Expertise in CPT and ICD coding, ensuring compliance with healthcare policies and regulations.
Overview
17
17
years of professional experience
Work History
Medical Insurance Advisor
United Healthcare
Anaheim, USA
01.2023 - Current
- Review, process, and adjudicate medical claims based on established policies, benefit plans, and provider contracts to ensure accurate payment and compliance.
- Apply CMS/Medicare guidelines, state mandates, and benefit plan documents to each claim to determine benefits and appropriate benefit payment.
- Examine claims for proper coding (CPT, ICD) and charges, manually adjust pended or escalated claims to resolve payment discrepancies, and ensure timely resolution.
- Create documentation for overpayments, communicate with providers and members to explain claim decisions, and support recovery efforts.
- Maintain high productivity standards (90+ claims/day) while ensuring at least 95% quality accuracy.
- Collaborate with healthcare providers and members, to resolve claim errors and clarify benefits using clear, simple language.
- Support system updates, participate in training on new policies, and ensure all claims reporting requirements are met, including daily production and pending reports.
- Assist members with benefit explanations, claim status inquiries, and resolution of complex claim issues via phone and electronic communication.
Benefits & Claims Support Specialist
Amity Foundation
Los Angeles, USA
09.2020 - 06.2023
- Reviewed client benefit eligibility and coordinated services, ensuring compliance with healthcare regulations, similar to claims review and benefit application processes.
- Assessed client needs, maintained detailed records, and advocated for benefits, aligning with claims documentation and interpretation of benefit plans.
- Collaborated with healthcare providers, legal, and social service agencies to facilitate claims processing and resolve complex issues.
- Resolved escalated client concerns, provided crisis intervention, and adjusted care plans, demonstrating problem-solving skills comparable to adjudicating complex claims.
- Maintained confidentiality and HIPAA compliance when managing sensitive client information, supporting regulatory adherence.
- Monitored case progress, documented outcomes, and generated reports, similar to claims tracking and reporting.
Retail Operations Supervisor / Customer Service Coordinator
AT&T Mobility
Torrance, USA
11.2015 - 09.2020
- Led daily store operations with a focus on compliance, operational procedures, and process improvement, analogous to adherence to claims processing policies.
- Managed high-volume customer interactions, resolving disputes, and providing clear communication—skills directly transferable to member/provider communication and claims error resolution.
- Ensured accurate recordkeeping and reporting of sales and operational activities, supporting quality and productivity standards.
- Trained and coached team members on process compliance and customer service, emphasizing attention to detail and adherence to standards.
Claims & Service Coordinator
AAA
Long Beach, USA
09.2012 - 11.2015
- Managed high-volume call handling, dispatching, and data entry, demonstrating efficiency in processing multiple requests and claims under pressure.
- Maintained detailed, confidential records of services provided, supporting claims documentation and audit requirements.
- Troubleshot and resolved urgent service issues, akin to manual adjustments and escalations in complex claims.
- Communicated technical and procedural information to customers, supporting clarity and stakeholder satisfaction.
Retail Sales & Customer Service Manager
T-Mobile
Torrance, USA
06.2008 - 09.2012
- Managed inventory, sales transactions, and ensured compliance with audit standards, reflecting accuracy and compliance required in claims review.
- Monitored team performance and sales targets, addressing deficiencies to maintain standards— paralleling quality control in claims processing.
- Delivered excellent customer service, resolving issues professionally, which translates into effective stakeholder communication in claims.
Education
Licensed Vocational Nurse Program -
American Career College at St. Francis
Lynwood, CA01.2012
High School Diploma -
Dominguez High School
Paramount, CA01.2005
Skills
- Medical claims review and processing
- CPT and ICD coding accuracy
- Benefits and contract interpretation
- Healthcare policy and compliance
- High-volume claims handling
- Claims escalation and resolution
- Overpayment recovery documentation
- Electronic claims management systems
- Member and provider communication
- HIPAA compliance standards
- Data entry and reporting
- Customer service
Timeline
Medical Insurance Advisor
United Healthcare
01.2023 - Current
Benefits & Claims Support Specialist
Amity Foundation
09.2020 - 06.2023
Retail Operations Supervisor / Customer Service Coordinator
AT&T Mobility
11.2015 - 09.2020
Claims & Service Coordinator
AAA
09.2012 - 11.2015
Retail Sales & Customer Service Manager
T-Mobile
06.2008 - 09.2012
Licensed Vocational Nurse Program -
American Career College at St. Francis
High School Diploma -
Dominguez High School