Claims Adjudication Specialist with Vision Focus

561-***-**** **********@*******.*** Boca Raton, Florida

MILANA

PRUZHANSKY

PROFILE

Analytical, detail-oriented, and efficient Claims Adjudication Specialist with extensive experience in processing and resolving diverse claims, including routine vision, medical, pass-through, appeals, and reinstatements. Proven expertise in data entry, process improvement projects, and training junior staff, with a strong commitment to accuracy and regulatory compliance. PROGRAMS

WORK EXPERIENCE

Plexis Claims Manager

Availity Essentials

eVips/Symplr Payer

Vistar & Premier Tracker

HNA Claims Processing System

Microsoft Office Suite

Claims Specialist / Routine Vision Training Team Lead Premier Eye Care/A Health Network One Company

Coral Gables, FL

2000-2025

o Adjudicated and processed a high volume of routine vision claims, medical claims, and pass-through claims, ensuring compliance with all policy provisions and regulatory guidelines.

o Analyzed claims to determine if all filing requirements were met, updating line items and resolving discrepancies to facilitate accurate payment. o Executed accurate and efficient data entry of all claim information, consistently maintaining a high accuracy rate while meeting daily productivity goals. o Led and contributed to various projects aimed at streamlining claims processing workflows.

o Managed the end-to-end processing of appeals and reinstatements, conducting thorough research and resolving complex discrepancies to ensure accurate outcomes.

o Served as the primary trainer and subject matter expert (SME) for routine vision claims processing, developing and delivering training materials to new team members.

Property & Casualty Insurance Account Specialist

Kurbatsky Boris Insurance Brokerage Brooklyn, NY 1987-2000

o Generated precise insurance quotes and conducted thorough client consultations and needs assessments for property and casualty coverage. o Processed new business applications for Automobile and Condominium insurance, delivering tailored coverage recommendations to meet client needs. o Oversaw comprehensive policy billing operations, managing down payments, processing monthly premiums, and executing account adjustments. o Facilitated the entire claims lifecycle, from handling initial accident reports and filing claims to serving as the dedicated client liaison with insurance carriers. o Ensured timely claim progress and resolution through persistent follow-up and communication with insurance providers.

o Provided consistent customer support, managed policy inquiries, and maintained meticulously organized client records and documentation. KEY SKILLS

Analytical and Problem-

Solving: Evaluate claims, identify

issues, and implement solutions to

resolve them accurately and

efficiently.

Detail-oriented: Meticulously review

documents and information to

ensure accuracy and compliance.

Communication: Clearly convey

information both verbally and in

writing to customers, colleagues,

and other stakeholders. This includes

negotiation, conflict resolution, and

listening.

Customer Service: Ensure accurate

and professional handling of all

claims.

Time Management: Prioritize tasks,

manage a caseload, and meet

deadlines effectively.

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