Lydia

Pitts

Ft Mitchell, Alabama *****

762-***-****

W: ady20z@r.postjobfree.com

Skills

• Claims investigation

• Case reporting

• Reserve management

• Records review

• Evidence collection

• Good communication

• Problem solving

• Self-starter

• Follow through

• Customer experience control

Professional Summary

Focused Claims Specialist offering over 20 years of claims processing experience. Investigates and verifies data to determine claims adjustment or processing documents all activity in Qcare,WGS and CIW systems. Excellent command of insurance terminology and industry best practices. Experience

Anthem/Bcbs of Georgia Midland, Georgia

January 2000 - June 2021

Sr. Claims Adjuster/Processor

Handled questionable claims by escalating to our Medical Review department.

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Examined claims forms and other records to determine insurance coverage and benefits.

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Paid and processed claims within designated authority level,as a Sr I adjusted both large dollar facility and professional claims daily.

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• Conferred with legal counsel on claims requiring litigation. Documented claims in full, entering payments, reserves and new information.

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• Reported overpayments, underpayments and other irregularities. Made accurate determinations based on information obtained from claimants and medical professionals.

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Maintained records of settled claims and inventory of claims requiring detailed analysis.

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Verified authorizations on previous investigations and questionable claims with more in-depth reviews

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Durable Medical and Chiro Specialist for my department all DME and Chiropractic claims would come to me at one point in the company.

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Worked along with customer service for provider escalations on call immediate adjustments.

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• Coding

• Sweep reports for company.

• Reviewed medical records for appeals.

Education

General education courses

Columbus College, Columbus, Georgia

June 1992

High School Diploma

Carver High School, Columbus, Georgia

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