Claims

ALEXIS WILLIAMS

**************@*****.*** 402-***-****

**Claims Specialist Customer Service Expert Medicare & Medicaid Experience**

**PROFESSIONAL SUMMARY**

Detail-oriented and highly experienced Claims Specialist with over 10 years in call center environments, specializing in health insurance claims, Medicare/Medicaid processes, fraud investigation, and customer resolution. Proven ability to handle high call volumes while maintaining compliance with HIPAA regulations. Skilled in claim adjudication, provider relations, and issue resolution.

**CORE SKILLS**

- Claims Processing & Adjudication

- Medicare / Medicaid Knowledge

- HIPAA Compliance

- Fraud Detection & Investigation

- EOB / COB Reviews

- Customer & Member Support

- Call Center Operations (Inbound/Outbound)

- Pharmacy & Prior Authorization

- Problem Solving & Escalation Handling

- Documentation & Case Management

**PROFESSIONAL EXPERIENCE**

**Accenture Flex** — *Claims Adjudicator / Content Reviewer / Coordinator*

*Remote 2021*

- Investigated unemployment claims flagged for fraud, determined validity, and communicated with claimants regarding account status.

- Conducted claims filing and documentation for escalated cases.

- Collaborated with internal teams via email and reporting to ensure proper content moderation and compliance.

- Maintained accurate records, scheduled team communications, and ensured deadline adherence.

**NRPG** — *Project Manager (Claims Call Center)*

*Remote 2020–2022*

- Led and managed political call center projects, including hiring, training, scheduling, and payroll.

- Oversaw inbound/outbound claims communication and fraud detection efforts.

- Reported key metrics to stakeholders and monitored risks to ensure successful project completion.

**Bank of the West** — *Online Banking Claims Specialist*

*Omaha, NE 2019–2021*

- Handled high-volume inbound calls related to account access, fraud cases, and billing inquiries.

- Conducted fraud analysis and case building for online and mobile banking platforms.

**LDI / CastiaRX** — *Mail Order Claims & Billing Specialist* Omaha, NE 2017–2019*

- Promoted to team lead; supervised call quality and conflict resolution.

- Managed pharmacy billing, PBM communication, and member outreach.

- Oversaw daily mail order claims and collaborated with account managers.

**Prime Therapeutics** — *Claims Specialist*

*Omaha, NE 2016–2017*

- Supported Medicare/Medicaid members on coverage determination, quantity limits, and clinical review processes.

- Facilitated direct communication with providers and pharmacies.

**West Corporation** — *Claims Specialist*

*Omaha, NE 2016*

- Conducted outbound calls to providers to recover overpayments.

- Reviewed and processed EOBs and COBs while maintaining HIPAA compliance.

**Sitel** — *Customer Service Representative*

*Omaha, NE 2012–2016*

- Handled 75–100 inbound calls daily for HBO/DirectTV billing and tech support.

- Resolved customer issues efficiently and improved satisfaction scores.

**CERTIFICATIONS**

- HIPAA Compliance Training

- Medicare/Medicaid Billing & Coding Review

- Pharmacy Claims Processing

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