Knowledge of basic office equipment such as computer systems
Tonya Boyd
Euclid,OH
Summary
Senior Claims Representative with 15 years of industry experience. Successful at meeting customer and company needs with fair and equitable approach to claims process. Detail-oriented, systematic and skilled in identifying exposures and proposing actionable solutions. Well-versed in handling claims with a consistent approach. Knowledgeable about determining coverage and liability, completing documentation and uncovering fraudulent claims. Forward-thinking and resourceful with strong communication and organizational abilities.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Senior Medical Claims Representative
CVS Pharmacy
10.2022 - Current
- Enhanced customer satisfaction with timely and accurate resolution of claims disputes.
- Enhanced customer satisfaction by promptly addressing concerns and providing accurate information.
- Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
- Developed strong product knowledge to provide informed recommendations based on individual customer needs.
- Assisted physicians with patient education efforts, providing resources and support as needed.
- Enhanced patient satisfaction by addressing inquiries and resolving issues related to medical appointments, billing, and insurance.
- Handled sensitive patient information with confidentiality, adhering to HIPAA regulations at all times.
- Educated patients on available healthcare services and assisted them in making informed decisions about their care options.
- Supported patients by providing clear explanations on insurance benefits, coverage limitations, and out-of-pocket costs.
- Verified insurance eligibility and coverage for patients.
- Investigated insurance claims denials and appeals.
- Facilitated smooth pharmacy operations by assisting with administrative tasks such as filing, documentation, and phone call management.
- Assisted pharmacist by filling prescriptions for customers and responding to patient questions regarding prescription and medication-specific issues.
- Filled and dispensed medication prescriptions accurately as ordered by physicians.
- Processed payments for prescriptions and accurately completed cash and credit card transactions.
- Answered questions regarding medication instructions and usage.
Senior Claims Adjuster
Progressive Insurance
11.2007 - 03.2022
- Reduced claim processing time by implementing streamlined procedures and efficient documentation practices.
- Enhanced customer satisfaction by promptly addressing and resolving complex claim issues through thorough investigation and analysis.
- Expedited claims settlements with successful negotiation strategies and effective communication skills.
- Improved team productivity, providing comprehensive training to junior adjusters on industry best practices and company guidelines.
- Optimized workload management, prioritizing time-sensitive cases to ensure timely resolutions for clients.
- Interviewed claimants and witnesses to gather factual information.
- Reviewed police reports, medical treatment records, and physical property damage to determine extent of liability.
- Substantiated legitimate claims and denied unjustified claims.
- Provided exceptional customer service during stressful situations, demonstrating empathy, patience, and professionalism throughout the entire claims process.
- Examined photographs and statements.
- Evaluated insurance policies and analyzed damages to determine coverage.
- Conducted comprehensive interviews of witnesses and claimants to gather facts and information.
- Assisted homeowners by coordinating vendor services, emergency repair, cleaning and contractors.
- Followed up on potentially fraudulent claims initiated by claims representatives.
Education
High School Diploma -
Life Skills Center Of North Akron
Akron, OH06.2000
Skills
- Investigations Expertise
- Claims Investigation
- Policy Interpretation
- Claims Analysis
- Fraud Detection
- Customer Service
- Insurance Knowledge
- Computer Proficiency
- Coverage Determination
- Small Claims Payouts
Certification
- Licensed Claims Adjuster - 2006-2022
- [Medical Billing and Claims] Training - 2022-2023
- [Pharmacy Claims] Training - 2022
Accomplishments
- Used Microsoft Excel to develop inventory tracking spreadsheets.
- Achieved bonusus and kudos through effectively helping with mentoring.
Software
Microsoft
Excel and production of spreadsheets
Timeline
Senior Medical Claims Representative
CVS Pharmacy
10.2022 - Current
Senior Claims Adjuster
Progressive Insurance
11.2007 - 03.2022
High School Diploma -
Life Skills Center Of North Akron