Michelle Flores
San Diego
Summary
Claims Technical Expert with 20+ years in claims processing and customer communication. Proven ability to resolve discrepancies and train junior staff, ensuring compliance and accuracy. Recognized for delivering exceptional customer service while processing high volumes of claims. Expertise in claims evaluation, fraud detection, and developing best practices to drive organizational success.
Overview
22
22
years of professional experience
Work History
Claims Technical Expert
Social Security Administration, SSA
La Mesa
09.2003 - 08.2025
- Processed claims efficiently using company-specific software and systems.
- Evaluated claim documentation for accuracy and completeness.
- Communicated with clients to clarify claim details and gather information.
- Provided training support to junior claims representatives on procedures.
- Processed a high volume of claims efficiently while maintaining quality standards.
- Provided quality customer service to assigned, insured and claimants throughout claims process to deliver timely service to customers.
- Handled customer inquiries regarding claim details and payment status updates.
- Reviewed and verified claim information to ensure accuracy of data and compliance with established policies.
- Provided clear explanations of benefits, eligibility requirements, and applicable laws when communicating with customers.
- Filed appeals on behalf of customers when necessary, after denial of a claim due to insufficient evidence.
- Adhered to strict guidelines pertaining to confidentiality while handling sensitive personal information.
- Verified details with claimant's and requested additional information.
- Ensured timely submission of required documentation from claimants prior to approval of payment.
- Resolved complex discrepancies in claimant files to facilitate accurate claim processing.
- Conducted research into medical terminology related to Disability claims processing activities.
- Identified potential fraud indicators during the review process and reported suspicious activity accordingly.
- Educated customers on their rights under state and federal regulations governing policies.
- Participated in audits and reviews of claims to ensure accuracy and adherence to guidelines.
- Conducted training sessions for new hires on claims processing procedures and best practices.
- Assisted claimants with problems or questions regarding claims.
- Served as a subject matter expert for retirement, survivors, health insurance, and Disability claims.
Education
Bachelor of Arts - Business Administration And Management
University of Phoenix
Tempe, AZ06-2015
Skills
- Claims processing and policy evaluation
- Fraud detection and attention to detail
- Problem solving and time management
- Effective communication skills
- Training and mentoring
- Customer support and service expertise
- Interpersonal communication and empathy
Languages
Spanish
Native/ Bilingual
Timeline
Claims Technical Expert
Social Security Administration, SSA
09.2003 - 08.2025
Bachelor of Arts - Business Administration And Management
University of Phoenix
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