Handle appeals and grievances.Work in a fast paced environment to oversee the resolution of appeals, meeting the Internal and External regulatory guidance.Work Medicaid appeals along with other COB.Worked appeals for timely filing, billing errors, no authorization and mismatch provider information.Adjusted Appeals in HRP.Documented and closed the complaint in Guiding Care and sent out denial letters to educate Providers on the decision of the appeal.

Provided hands-on assistance with the claim adjudication process through verification of coverage for eligibility and discrepancies, applying all cost containment measures.Identified, reviewed, or applied appropriate guidelines, coding, member and provider selection processes, and claim coding (i.e., procedure, diagnosis, and pre-coding requirements) through proofing of claims or referral submission.Used VBA system to process claimsCOBResearch and resolve issues in VBAAssisted with sending updated info to configuration team migrate updated contracts to VBA.

Processes or adjust medical insurance claims in accordance with policies and procedures.Responsible for having the ability to read explanation of benefits, claim forms and healthcare terminology. Identifies, researches, resolves claim issues, and requests for additional documentation. Ensures contractual performance guarantees related to payment processing timeliness and accuracy are met. Processes medical payments.

- Recognized as a highly analytical claims benefits specialist due to demonstrated skills in the thorough analysis and adjudication of routine claims based on claim processing and medical necessity guidelines.- Provided hands-on assistance with the claim adjudication process through verification of coverage for eligibility and discrepancies, applying all cost containment measures. - Identified, reviewed, or applied appropriate guidelines, coding, member and provider selection processes, and claim coding (i.e., procedure, diagnosis, and pre-coding requirements) through proofing of claims or referral submission. Research and respond to service requests in a prompt and timely manner Update or build configuration in HRP as needed. Research and resolved issues within HRP.Uploaded provider contracts from pdf format into HRP.

- Adhered to all company and insurance clients’ guidelines on work conduct, customer service, policy, claims process, estimate writing, and claim closures associated with claim assignments.- Coordinated closely with stakeholders (i.e., insureds, claimants, vendors, carriers, witnesses, public adjusters, attorneys) via phone or email to gather and discuss pertinent information to support claims. - Evaluated property claims to confirm coverage, examined field reports, and assessed damage to fairly deny, settle, or authorize payments for property claims; expanded claim handling procedures as necessary to complete within the required statutory time frame; prepared technical claim documents and correspondence.

- Played a key role as primary point of contact to expertly handle commercial insurance property catastrophe claims from clients; visited and examined property to evaluate damage and determine claimant compensation for the insurance company. - Performed a variety of activities ranging from investigation to settlement, including mitigating the needs of the affected, interviewing claimants, ensuring safety of every resident, physically analyzing scope of interiors and exterior damage to properties, and submitting photos and estimates via Xactimate.- Worked closely with desk adjuster to finalize claim estimate and prepare payment; regularly conducted follow-ups with insured on estimates and payments.

- Orchestrated a variety of client projects throughout the entire project lifecycle, including customer implementations, requiring knowledge of industry best practices; created plans/timelines; managed budgets up to $100K; allocated resources; defined scope; identified and mitigated risks; provided status update reports, release management, change submission, and approvals to senior leadership and internal business partners. - Collaborated across functions (i.e., Product, QA, Account, Customer Service teams) to execute and monitor professional services implementation queue, along with project milestones and deliverables. - Maximized customer satisfaction and experience as the manager consultant for Best Buy; facilitated product demos to customers to educate them on new Samsung products and services, while troubleshooting issues and resetting displayed products as needed.

- Promoted to project manager as a direct result of project management expertise, strategic leadership, and the demonstrated ability to lead and build high-performing teams.- Led and accomplished special projects, including client needs assessment, strategic planning based on demands, PRD development, goal setting, and stakeholder communication with status updates, release management, change submission, and approvals. - Liaised among applicants and new hires throughout the onboarding process, following job offers, including:o Database management (i.e., profiling, background checks, I-9 documentation) via E-Verify, payroll processing via Peoplesoft software, accounting records and documentation via MS Excel, program and production inventory documentation repositories, framework, and workflow tools via SharePoint.o Regulatory compliance, ensuring all written instructions, manuals, company policies, safety standards, and pay guidelines were followed from start to finish.o New hire kit, including uniform vouchers and annual replenishment ordering, as well as other concerns and/or inquiries in a timely manner.