Fraud & Claims Operations Specialist
Resume:
Monique Lewis
Waddell, AZ *****
***************@*****.***
Career Objective
I can work in a dynamic, hands-on, multi-faceted environment. I have innovative and analytical abilities that are influenced for teamwork and help to create outstanding solutions. My mission is to work diligently for the best interest of the account holders and the company.
Education
2000-2004 Wooddale High Memphis, TN 38115
2005-2006 Associate of Arts Collins College Tempe, AZ 85281
2006-2007 Bachelor of Arts Collins College, Tempe, AZ 85281
Software
Microsoft Word Microsoft Outlook Lexis Nexus
Microsoft Excel Microsoft PowerPoint C.L.A.I.M.S.
Salesforce LexisNexis Hogan
OneNote Intellicheck ACH History
eTran MARS CIV
Experience
Wells Fargo Chandler, AZ
Senior Fraud Claims & Operations Representative November 2022-Present
Support team performance in identifying control failures in bank processes, procedures, customer, or colleague decisions.
Provide feedback and present ideas for improving or implementing processes and tools within fraud and claims functional area.
Perform complex operational tasks, including review, verification, and identification of customer transactions to detect and prevent fraud, policy violations and resolve merchant disputes to mitigate and recover losses.
Interact with fraud and claims functional area on a wide range of information as well as with external customers.
Review transaction history with customers and provide tools to prevent further fraudulent activity.
Make outbound calls to customers to obtain additional information needed to process their claim(s).
Process claims on time to adhere to REG E guidelines.
American Express Phoenix, AZ
Account Protection Specialist July 2021-June 2022
●Answered incoming calls from card members
●Validated caller’s identity by using various security measures
●Reviewed potential fraudulent charges with cardholders
●Invalidated and replaced cards affected by fraud
●Replaced lost and stolen cards
●Reported fraudulent accounts
●Set up fraud cases for confirmed fraudulent charges
●Verified card member’s demographics
●Sent trending fraud charges to leadership for review
●Updated and Corrected account information that was compromised
●Placed outbound calls to Card Members after receiving suspicious calls about their account
●Reviewed fraud case status with card members
AZ Pain Doctors Phoenix, AZ
Authorization Specialist July 2020 & July 2021
●Submitted authorizations to insurance companies for review of surgical procedures
●Verified patient’s insurance coverage and benefits
●Processed urgent procedure tasks from Providers
●Contacted insurance companies to confirm CPT billing codes required for authorization of a Patient’s plan
●Sent messages to Providers to update chart notes with imaging requests
●Sent tasks to outbound representatives to obtain percentage of relief from completed injections
●Reviewed insurance medical policies
●Reached out to insurance companies to request for more Chiropractic visits
●Reviewed medical documents from patient’s office visits
●Updated chart notes with approvals or denials from submitted authorizations
●Submitted appeals to insurance companies on behalf of the patients
●Faxed requested clinical information to insurance companies for review
AMEX Assurance Company Phoenix, AZ 85054
Claims Adjuster February 2018-July 2020
●Processed and adjudicated claims submitted by card members
●Answered inbound calls from intake representatives and card members regarding the status and outcome of their claim(s)
●Processed Appeals on denied claims
●Placed outbound calls to various merchants and manufacturers for warranty coverage and return policies
●Researched charges to make sure there were no disputes on the items being claimed
●Contacted various police departments to verify police/incident reports
●Educated card members on the insurance benefits included with their cards
●Submitted requests for additional information to card members on their pending claims
●Processed upfront denials on claims that included ineligible items or if the loss was outside of our coverage period
●Reached out to repair facilities to verify repair estimates for claimed items
●Verified Homeowner’s Insurance for theft claims
●Reviewed official fire reports for items damaged by fire
●Assisted SIU in obtaining information from card members
●Submitted case information to SIU for further investigation
TriWest Healthcare Alliance Phoenix, AZ 85053
Quality Control & Escalation Specialist August 2015- February 2018
Handled escalated cases submitted by the VA and congressional offices
Submitted daily updates on assigned cases to the VA and congressional offices.
Conducted daily audits on staff members for authorization entry and appointing
Sent Critical Finding emails on errors made by staff for corrections and coaching opportunities.
Train new auditors for Quality Control
Conducted internal audits on auditors.
Helped to maintain reference guide for Quality Control to reflect current policies and procedures
Researched and completed administrative fund requests submitted by the VA, providers, and internal staff.
TriWest Healthcare Alliance Phoenix, AZ 85053
Complex Authorization Specialist May 2014-August 2015
●Reviewed and processed referrals from various VA hospitals
●Set up appointments for Veterans to receive medical care
●Trained new staff members on authorization entry
●Reviewed medical documentation from Providers
●Processed Secondary Authorization Requests from Providers for additional needed care
●Reviewed authorizations that needed to be amended and or corrected
●Contacted Providers to receive CPT billing codes for services and surgical procedures
●Consulted with the VA for missing information or approvals for additional services
McKesson/RemX Staffing Scottsdale, AZ 85251
Data Entry Clerk. December 2013-May 2014
●Reviewed patient’s applications for assistance
●Made follow up calls on pending cases to obtain missing information
●Input data from the applications into database systems
●Submitted prescriptions for approved applications
Cigna Home Delivery Pharmacy Phoenix, AZ 85027
Data Entry Clerk/Customer Service November 2011- May 2013
●Refilled and Renewed customer Prescriptions
●Signed up new and existing customers up with Home Delivery services
●Used multiple systems to update customer information
●Made follow up calls to Doctors and Pharmacies regarding customer's prescriptions
●Checked the status of orders that were processing for inquiring customers
●Reviewed Pharmacy benefits and prescription co-pay amounts with members
●Filed claims for members to replace lost, stolen or damaged medications
●Processed payments on member’s accounts
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