Claims Specialist Insurance Verification

Adrienne Jackson

***** *******, ** +1-910-***-**** *************@*****.***

Summary

Skilled Claims Specialist with 10+ years of experience in healthcare claims, insurance verification, and reimbursement resolution. Proficient in managing high claim volumes, resolving denials, and working with Medicaid, Medicare, and commercial payers. Strong communicator with expertise in EPIC, Salesforce, and other healthcare systems. Seeking to contribute to a fast-paced team in an Associate or Claims Specialist role. Skills

Driving

Negotiation

Merchandising

Computer literacy

Antivirus software

Team collaboration

Hospital Experience

Insurance Verification

Experience with children

Interpersonal communication

Health insurance claim processing

Insurance claim appeals processing

Experience

01/2020 - 01/2025

Unified Women's Healthcare of NC - Headquartered in Boca Raton FL Managed comprehensive follow-up of all outpatient claims related to OB/GYN and maternity deliveries across multiple insurance providers.

Maintained frequent communication with insurance carriers via phone and online platforms to ensure timely claims resolution.

Audited paid claims against contractual agreements to identify discrepancies and ensure proper reimbursement. Coordinated the ordering and tracking of medical records to dispute denials due to lack of authorization or insufficient information.

Investigated and resolved non-specific insurance denials through thorough documentation and proactive follow-up. Processed and initiated appropriate refund requests to insurance carriers for individual care centers in accordance with policy.

C.S.R. AETNA MEDICARE ADVANTAGE 07/2019 - 01/2020 Continuum Global Solutions - NC

Processed premium payments and managed member enrollment and disenrollment activities in compliance with plan guidelines.

Handled requests for re-issuance of member ID cards, ensuring timely and accurate delivery. Researched and resolved complex claim issues, including overpayments, underpayments, and denials across multiple benefit areas.

Facilitated reimbursement resolution for dental, vision, and hearing aid claims. Addressed and documented oral grievances, ensuring timely follow-up and resolution in accordance with regulatory requirements.

REIMBURSEMENT CASE MANAGER RYTARY/JANSSEN CAREPATH 01/2018 - 01/2019 Aerotek/Trialcard - Morrisville, NC

Acted as a liaison among patients, physician offices, pharmacies, and insurance companies to facilitate communication and resolve issues.

Conducted thorough benefit investigations to determine patient eligibility and coverage details. Managed patient enrollment into assistance and charity programs to support access to necessary treatments. Issued payment vouchers and copay cards to pharmacies to ensure seamless patient medication access. INSURANCE SPECIALIST 01/2017 - 01/2018

PFS Group - Morrisville, NC

Verified insurance coverage and eligibility through online systems and direct phone communication. Conducted timely follow-up on billed claims and managed re-billing of denied claims to ensure accurate reimbursement.

Participated in the Albert Einstein Hospital project, contributing to claims processing and insurance coordination. PATIENT ACCOUNTS REPRESENTATIVE 01/2014 - 01/2017 Amcol Staffing WakeMed Health and Hospitals - Raleigh, NC Served on the Government Medicaid team, managing follow-up on unpaid claims to ensure timely payment. Contacted patients to obtain and update current insurance information, maintaining accurate records. Re-billed corrected claims to address discrepancies and optimize reimbursement. Audited paid claims against contract terms to verify compliance and identify payment variances. ACCOUNTS RECEIVABLE REPRESENTATIVE II/LEAD REP 01/2004 - 01/2014 North Shore Long Island Jewish Health System/Northwell - Westbury, NY Led special projects focused on collecting past-due invoice charges for cardiac implants, securing over $1,000,000 in retroactive payments.

Reduced over 90-day aging of low-dollar claims, resulting in $54,000 collected within 10 weeks. Trained and onboarded new hires, ensuring adherence to departmental processes and standards. Managed follow-up on inpatient and outpatient facility claims within the healthcare system. Maintained frequent communication with insurance carriers through phone and online platforms to resolve claim issues.

Audited paid claims against contract terms to ensure accuracy and compliance. Collaborated with patients to support collection of outstanding claims and resolved all administrative denials. Handled all necessary correspondence to facilitate timely resolution of claims. Education and Training

High school diploma or GED

State University of Farmingdale - Phlebotomy (Certificate) Malloy College-Rockville Centre - NY ICD-9 (Certificate) Nassau Community College-Garden City - NY Merchandising (AAS) Experience

Healthcare claims specialist

Additional Skills

Insurance Claims Expertise: 6+ years of experience in claims processing, adjudication, adjustments, and appeals; capable of managing high claim volumes (100–200 weekly) across Medicare, Medicaid, and commercial payers. Claims Investigation & Auditing: Skilled in identifying billing discrepancies, resolving denials, and ensuring compliance with payer contracts and policies.

Technical Proficiency: Proficient in healthcare systems including EPIC, Cerner, Salesforce, IDX, Invision, SSI, Dentrack, Canopy, Omnipro, Cubs, SMS, Star Navigator, and additional platforms such as Rapid Rebate, E Cases, Huron Aeos, and Stockcamp TRAC.

Software & Systems: Experienced with ICD-9 coding, Microsoft Windows, contract management tools, and various productivity software.

Communication & Support: Strong phone communication skills, call center experience, and effective in patient and provider engagement.

Organizational Strengths: Highly organized with excellent pattern recognition skills, able to prioritize tasks in fast-paced environments.

Healthcare Knowledge: Familiar with senior care workflows and medical reimbursement processes.

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