I currently work in Claims System-Intake and Resolution where I support claims operational teams by investigating and analyzing system issues relating to claims processing. This involves researching source material, engaging key stakeholders, pulling reports, analyzing data, and providing guidance in resolving issues reported. I work both independently and collaborate within the team and other teams to develop solutions that will enhance and create efficiencies.I am responsible for reviewing and responding to PG, MTM, and internal audit findings as well as DMHC escalations involving system issues. This entails determining root cause, identifying impacted volumes, implementing a fix, ensuring controls are in place to prevent issue from reoccurring, and remediating impacted claims.

Claims Documentation Content Owner responsible for maintaining and updating 300+ claims desk level procedure documents used for the processing of provider and member submitted claims. Responsibilities include but are not limited to: approving and/or rejecting document update requests, validating updates for accuracy, tracking document updates per red-lined process, testing updates on live claims, ensuring document is audit ready, performing governance, publishing updates, etc.

Hospital Exceptions and Transplants (HEAT) claims processor responsible for manually pricing high-dollar transplant and hospital exception claims. Responsibilities included but were not limited to: correctly interpreting provider contracts to determine if exception criteria is met, manually calculating and pricing exceptions such as stoploss, trauma, implants, pharmaceuticals, blood, and transplants, and ensuring claim passes high-dollar audit review.

Responsible for assisting the anti-fraud manager with researching potential U.S. citizen imposters. This involved running applicable background searches, reviewing older birth and death certificates via microfiche, reviewing submitted citizenship documents for authenticity, tracking and logging data and trends, assisting Diplomatic Security with case preparation prior to an imposter’s arrest, creating educational fraud PowerPoint trainings for the passport adjudicators, etc.

Owned and operated an auto insurance brokerage. Sold auto insurance policies to licensed California drivers, managed policies, accepted and apllied monthly insurance premiums to policies, assisted with claims filings and policy renewals, as well as all other forms of customer service.