Medical Payment Adjuster and Claims Specialist

Clovis Bailey, Jr.

469-***-**** **************@***.***

Cedar Hill, TX

Professional Summary

Detail-oriented and highly skilled Medical Payment Adjuster with over 6 years of experience in insurance claims investigation, adjudication, and resolution. Proven ability to interpret policy coverage, evaluate medical documentation, and issue timely and accurate payments. Adept at maintaining compliance with HIPAA, state, and federal regulations while delivering exceptional customer service and fostering positive relationships with claimants, providers, and legal representatives.

Professional Experience

Medical Payment Adjuster

Sedgwick Claims, Remote Dec 2024 – Oct 2025

• Reviewed policy coverage and verified Med Pay applicability for auto-related incidents.

• Analyzed medical records, invoices, and diagnostic reports to validate treatment relevance.

• Authorized and processed payments to providers or reimbursed policyholders.

• Maintained accurate reserves and pursued subrogation when applicable.

• Served as primary contact for claimants and clients, ensuring transparency and satisfaction.

Property Claims Adjuster

Citizens Property Insurance Corp., Remote Sep 2023 – Dec 2024

• Investigated and settled property claims per Citizens’ Best Practices.

• Interpreted policy contracts and state statutes to determine coverage.

• Utilized estimating software and documented findings in claims systems.

• Participated in catastrophe response and ensured regulatory compliance. Medical Claims Specialist

Multiplan, Arlington, TX Apr 2017 – May 2019

• Evaluated medical claims using HCPCS, ICD-10, and CPT codes.

• Verified claim status via payer portals and resolved denials.

• Ensured compliance with HIPAA and optimized reimbursement processes. Property Desk Examiner

Wellington Insurance, Remote Feb 2021 – Nov 2021

• Handled various property claims including theft, liability, and mitigation.

• Collaborated with attorneys, public adjusters, and vendors to resolve claims.

• Delivered timely updates and ensured customer satisfaction.

Education

Cedar Hill High School, Cedar Hill, TX

High School Diploma Aug 2013 – Jun 2017

Licenses & Certifications

• All Lines Adjuster Licenses: TX, FL, LA, GA

• Certifications: NFIP Flood, Citizens Certification

Technical Skills

• Claims Systems: Guidewire, Claim Center, File-Trac, EPIC, Facets, Salesforce, Lexis Nexis

• Estimating Tools: CCC Pathways, Audatex, Xactimate, XACT Contents

• Platforms: MS Office Suite, Citrix, Oracle, SQL, Zoom, Teams

• Compliance: HIPAA, ERISA, COB, NSA, Fair Claims Practices

Core Competencies

• Medical Billing & Adjudication

• Claims Investigation & Resolution

• Policy Interpretation & Coverage Analysis

• Customer Service & Communication

• Subrogation & Reimbursement

• Multi-Jurisdictional Claims Handling

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