Vongai Mpesi
St Augustine
Summary
Analytical claims professional with 4+ years of experience investigating, reviewing, and resolving high-volume insurance claims in remote environments. Skilled in analyzing claim details, determining coverage and liability, and identifying discrepancies through detailed documentation review and data analysis. Proven ability to manage complex caseloads, apply policy guidelines, and make sound decisions while maintaining high accuracy and productivity standards. Strong communicator with a focus on delivering fair, compliant, and customer-centered claim outcomes.
Overview
8
8
years of professional experience
Work History
Claims Investigative Specialist
Harvard Pilgrim Health Care
02.2021 - Current
- Investigate complex claim files to verify validity, accuracy, and compliance with policy and regulatory guidelines
- Analyze claim details to determine coverage, liability, and potential discrepancies across high-volume caseloads
- Review documentation, EOBs, and claim history to identify inconsistencies and potential risk indicators
- Conduct research and fact-finding using internal systems to support claim decisions and resolution strategies
- Apply policy interpretation and analytical judgment to support fair claim determinations and payment decisions
- Communicate with providers and internal stakeholders to clarify missing or conflicting information
- Manage multiple claims simultaneously while maintaining 98%+ quality scores and meeting productivity metrics
- Partner with internal teams on escalated claims, disputes, and complex investigations
- Remote
Claims Examiner
Cigna
06.2019 - 12.2020
- Examined and processed claims by validating eligibility, coverage, and provider network status
- Investigated claim details and analyzed documentation to determine appropriate claim outcomes
- Applied CPT, ICD-10, and HCPCS coding standards to ensure compliant reimbursement
- Identified discrepancies and supported resolution of complex or escalated claims
- Collaborated with internal teams to ensure accurate and timely claim processing
- Maintained compliance with policy guidelines and regulatory standards
- Remote
Claims Processor
UnitedHealthcare (UHC)
01.2018 - 01.2019
- Processed high-volume claims while ensuring accuracy, completeness, and policy compliance
- Verified member eligibility, coverage, and provider participation
- Reviewed claim forms (CMS-1500, UB-04) for accuracy prior to processing
- Investigated and resolved claim discrepancies including duplicates and missing information
- Calculated reimbursements using fee schedules, contract terms, and plan guidelines
- Supported appeals and documentation review processes
- Remote
Education
Bachelor of Arts -
University of Dayton
Skills
- Insurance Claims Investigation
- Coverage & Liability Determination
- Claims Analysis & Decision-Making
- Fraud & Discrepancy Identification
- Subrogation Awareness
- Claims Resolution & Case Management
- Policy Interpretation & Application
- Documentation Review & Validation
- Customer & Provider Communication
- Analytical Thinking & Problem Solving
- Time Management & High-Volume Workloads
- Claims Systems & Data Analysis
- HIPAA Compliance & Confidentiality
- Written & Verbal Communication
Timeline
Claims Investigative Specialist
Harvard Pilgrim Health Care
02.2021 - Current
Claims Examiner
Cigna
06.2019 - 12.2020
Claims Processor
UnitedHealthcare (UHC)
01.2018 - 01.2019
Bachelor of Arts -
University of Dayton