Michelle Flores
Hagerstown
Summary
Adept at navigating complex claims processes, I leveraged critical thinking and exceptional communication skills at United Healthcare to enhance claims resolution efficiency and customer satisfaction. My expertise in regulatory compliance and collaborative approach have consistently improved operational workflows, demonstrating a commitment to excellence and a profound ability to multitask effectively.
Overview
25
25
years of professional experience
Work History
Claims Adjustment Specialist
United Healthcare
07.2016 - Current
- Handle escalated customer complaints professionally and courteously while maintaining focus on finding satisfactory resolutions.
- Investigate discrepancies between policy coverage details and filed claims; recommended appropriate course of action resulting in cost savings.
- Participate in cross-functional team projects aiming to improve company-wide efficiency, communication, and collaboration for better customer service delivery.
- Improve claim processing efficiency by implementing new software and streamlining workflows.
- Enhance customer satisfaction by providing timely and accurate claim resolutions.
- Evaluate current processes regularly, identifying areas of potential improvement to boost overall department efficiency levels consistently over time.
- Stay up-to-date on industry regulations and best practices, continuously enhancing knowledge base for improved job performance.
- Manage a high volume of daily phone calls and emails from customers promptly addressing concerns/questions about the ongoing process.
- Streamline communication with clients through regular updates on claim status, fostering a positive experience during difficult times.
- Analyze complex data to identify trends in claims, recommending adjustments to policies and procedures accordingly.
- Establish effective working relationships with external partners such as medical providers, legal representatives, and repair facilities for seamless collaboration on claims resolution efforts.
- Collaborate with other departments for smooth inter-departmental communication regarding complex claims issues.
- Attend meetings, conferences and workshops, staying informed of emerging trends in claims adjustment processes for continuous improvement efforts.
- Reduce claims backlog by prioritizing tasks and effectively managing caseloads.
- Maintain thorough documentation to support claim decisions, ensuring compliance with company policies and industry regulations.
- Examine claims forms and other records to determine insurance coverage.
- Investigate and evaluate insurance claims to determine coverage, liability, and ensure proper adjustments are made
- Deliver exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Identify insurance coverage limitations with thorough examinations of claims documentation and related records.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Research claims and incident information to deliver solutions and resolve problems
Bartender
Famous Dave's Bar-B-Que
04.2000 - 03.2020
- Served high customer volumes during special events, nights, and weekends.
- Managed cash handling duties responsibly, ensuring accurate accounting at the end of each shift.
- Performed opening and closing duties, printing sales reports, setting up for incoming shift, preparing cash drawers, and taking inventory.
- Efficiently opened or closed the bar according to established procedures, ensuring preparedness for each shift.
- Developed loyal clientele by consistently delivering outstanding service and engaging in friendly conversation.
- Kept bar presentable and well-stocked to meet customer needs.
- Followed alcohol awareness procedures for preventing excessive guest intoxication.
- Trained new bartenders on drink preparation, product promotion, garnish preparation, and sanitation protocol.
- Organized bar inventory and storage procedures to keep stock within optimal levels and meet expected customer demands.
- Upsold menu items to customers, driving up per sale revenues and maximizing profits.
- Adhered to state laws regarding alcoholic beverage services and customer regulations.
Orthodontic Assistant
Dr. Kurt Pierce
06.2012 - 07.2016
- Prepared patient for orthodontist and performed simple tasks such as tightening braces and conducting preliminary examinations.
- Demonstrated strong communication skills while educating patients on oral hygiene practices specific to their orthodontic treatments.
- Took x-rays, photographs, and impressions of patients' teeth and mouth.
- Provided exceptional chairside assistance to orthodontist during complex procedures such as bracket placement and adjustments, aligner fittings, and appliance installations.
- Increased overall patient satisfaction by promptly addressing any discomfort or concerns related to their treatments.
- Assisted in fabricating custom orthodontic appliances tailored to individual patient needs.
- Enhanced practice efficiency by maintaining well-organized inventory of orthodontic supplies and equipment.
- Poured and shaped molds from impressions and trimmed molds in grinder.
- Set appointments and made follow-up calls.
- Promoted positive patient experiences by building rapport and addressing concerns during appointments.
- Reduced appointment wait times with efficient room setup and breakdown between patients.
- Prepped examination rooms, sterilized equipment and instruments and maintained appropriate tray setup.
- Developed comprehensive knowledge of various orthodontic appliances, enabling accurate preparation for each procedure.
- Ensured high-quality patient care through strict adherence to infection control protocols and sterilization procedures.
- Reduced appointment cancellations by following up with patients and providing reminders and motivational support.
- Assisted in minor orthodontic procedures, ensuring treatments were carried out smoothly and effectively.
- Assisted orthodontists in applying braces, which led to successful treatment outcomes and patient satisfaction.
- Prepared and sterilized instruments and treatment areas, ensuring safe and hygienic environment for every patient.
Education
Certificate - Orthodontics
Dental Assisting National Board
Columbia, MD04-2013
Associate of Science - Surgical Technology
Frederick Community College
Frederick, MD06-2010
Skills
- Claims Analysis
- Claims Management
- Regulatory Compliance
- Policy interpretation
- Teamwork and collaboration
- Problem-solving
- Claims adjustment
- Highly motivated
- Attention to detail
- Multitasking and organization
- Critical thinking
- Verbal and written communication
- Caseload management
Timeline
Claims Adjustment Specialist
United Healthcare
07.2016 - Current
Orthodontic Assistant
Dr. Kurt Pierce
06.2012 - 07.2016
Bartender
Famous Dave's Bar-B-Que
04.2000 - 03.2020
Certificate - Orthodontics
Dental Assisting National Board
Associate of Science - Surgical Technology
Frederick Community College
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