Kimberly Saylor
Claims Examiner
Gonzales
Summary
Licensed Claims Professional with 7+ years of experience investigating and managing complex claims, including medical-based determinations and regulatory compliance. Skilled in analyzing documentation, identifying discrepancies, and making coverage-related decisions in high volume environments. Strong background in claims investigations, escalations, and multi-state compliance with a focus on accuracy and timely resolution.
Overview
18
18
years of professional experience
2
2
Certifications
Work History
Senior Disability Representative
Sedgwick Claims Management Services
12.2023 - Current
- Managed a high volume of claims weekly ensuring timely and accurate claim determinations in a high-volume environment
- Conduct claim investigations by reviewing documentation, identifying gaps, and gathering required information
- Analyze medical and supporting documentation to determine eligibility, coverage, and claim outcomes
- Apply policy provisions and regulatory guidelines to support decisions and maintain compliance
- Identify and resolve payment discrepancies, overpayments, and claim errors.
- Communicate with claimants, providers, and employers to obtain information and resolve claim issues
- Handle escalated and complex claims, providing clear explanations and manage difficult conversations
- Maintained detailed claim documentation in systems (TAMS, Juris) to support decisions and audit readiness
- Serve as a resource for team members on complex claims, multi-state requirements, and claim handling processes.
Healthcare Specialist
MDLIVE Telehealth
07.2019 - 11.2022
- Assisted patients and providers while ensuring compliance with healthcare regulations and HIPPA standards
- Coordinated care and resolved issues by communicating with multiple parties in a fast-paced environment
Claims Processor
Modivcare
10.2008 - 06.2019
- Processed claims, verified eligibility, and ensured documentation accuracy for compliance
- Reviewed claim details and resolved discrepancies to maintain quality and efficiency
- Medical terminology application for claim evaluation
- Payment analysis, offsets, and financial accuracy
- Investigation and documentation review
Education
Bachelor of Science - Health Information Management
University of Arizona Global Campus
05.2001 -
Skills
- Claims Investigation
- Coverage Analysis
- Liability Assessment
- Medical Documentation Review
- Regulatory Compliance
- Subrogation Awareness
- Vendor & Stakeholder Communication
- Negotiation & Problem Solving
- Microsoft Office
- Claims Systems: TAMS, Juris
Accomplishments
- Louisiana Property and Casualty Adjuster
License - Active, Designated Home State
- New York Independent Adjuster License - Active
- Additional states available through reciprocity upon request
Certification
Louisiana Property & Casualty Claims Adjuster License – Active
Timeline
Louisiana Property & Casualty Claims Adjuster License – Active
01-2026
New York Independent Adjuster License
10-2025
Senior Disability Representative
Sedgwick Claims Management Services
12.2023 - Current
Healthcare Specialist
MDLIVE Telehealth
07.2019 - 11.2022
Claims Processor
Modivcare
10.2008 - 06.2019
Bachelor of Science - Health Information Management
University of Arizona Global Campus
05.2001 -