Jeanene M. Barron
Hemet
Summary
Results-driven Claims Analyst with expertise in claims analysis, risk assessment, and process improvement. Proven ability to enhance efficiency and ensure compliance while executing thorough investigations.
Overview
21
21
years of professional experience
Work History
Claims Analyst
Optum
Hemet
08.2004 - Current
- Analyzed claim data to identify discrepancies and ensure accuracy in processing.
- Collaborated with stakeholders to streamline claims review processes and enhance efficiency.
- Performed risk assessments to evaluate potential fraud in submitted claims.
- Documented system updates and procedural changes to maintain compliance with regulations.
- Executed thorough investigations to support claims resolution and mitigate losses.
- Communicated with customers to clarify claim details and gather necessary information.
- Reviewed policy coverage details to assess claim eligibility and validity.
- Identified trends in claims data to recommend improvements in processing workflows.
- Trained new team members on claims analysis procedures and best practices.
- Maintained accurate records of all claim activities in accordance with company policies.
- Followed all company procedures to keep data confidential.
- Reviewed customer claims, identified discrepancies and determined appropriate course of action.
- Assessed medical records for coverage eligibility and benefit accuracy.
- Assessed processing reports each day to effectively submit claims.
- Prepared detailed reports on claim status, payment history, and other relevant information.
- Participated in meetings with internal departments or external vendors as necessary to discuss disputed claims or other related matters.
- Managed escalated cases involving high-value claims or multiple parties involved.
- Gathered proper documentation and data to prepare claims for submission.
- Reviewed appeals filed by claimants who were dissatisfied with initial decisions made concerning their cases.
- Investigated fraudulent claims by gathering evidence from various sources.
- Researched applicable laws and regulations related to insurance policies and procedures.
- Analyzed claim data to identify trends and recommend process improvements.
- Ensured compliance with federal and state regulations governing insurance industry operations.
- Evaluated requests for additional benefits or changes in existing coverage levels.
- Reviewed documentation to verify accuracy of information provided by customers.
- Conducted investigations to gather evidence in support of claims resolution.
- Verified documents to ensure accuracy of information provided by customers.
- Investigated claim and settlement deals and reviewed coverage determinations.
- Developed strategies for resolving complex claims issues.
- Advised customers on filing requirements, documentation needed, and other matters pertaining to their claims.
- Prepared recommendations for management regarding potential liability exposures associated with certain types of claims.
- Assisted in the development and implementation of claims procedures to improve efficiency.
- Managed workload effectively to ensure timely processing of claims within designated deadlines.
- Input claim information and payments into company database.
- Discussed current cases and issues in claim committee meetings.
- Reduced loss ratios through fair and prompt processing of claims.
- Drafted statement of loss to summarize damages, payments and underlying policy coverage.
- Verified liability extent with reviews of police reports, medical treatment histories and other records.
Education
Some College (No Degree) - Administration
Napa Valley College
Napa, CASkills
- Claims analysis
- Risk assessment
- Claim documentation
- Fraud investigation
- Policy evaluation
- Customer relationship management
- Data verification
- Compliance assurance
- Process improvement
- Effective communication
- Problem solving
- Time management
- Trend identification
- Team training
- Detailed reporting
- Analytical and critical thinking
- Attention to detail
- Dependable and responsible
- Microsoft Word
- MS office
- Remote office availability
- Conflict resolution
- Customer relations
- Organizational skills
- Problem-solving
- Relationship building
- Quality assurance
- Organization
References
References available upon request.
Timeline
Claims Analyst
Optum
08.2004 - Current
Some College (No Degree) - Administration
Napa Valley College