Kelli Hawkins
Chattanooga
Summary
Claims Analyst with 25+ years of experience reviewing, investigating, evaluating, and adjudicating insurance claims in healthcare and property/casualty environments. Skilled in policy interpretation, coverage determination, documentation review, regulatory compliance, and delivering accurate claim decisions while meeting quality and productivity standards. Proven success working remotely, collaborating across departments, and providing exceptional service to members, providers, and internal stakeholders
Overview
27
27
years of professional experience
Work History
Claims Specialist - Auto Injury Third Party Tier 2/3
State Farm
07.2022 - Current
- Investigated, evaluated, and resolved complex insurance claims, ensuring compliance with company policies and state regulations to facilitate timely resolutions.
- Review claim documentation, verify coverage, determine liability, and authorize claim payments within established authority limits.
- Analyze evidence and supporting documentation to make accurate and timely claim decisions.
- Communicated with policyholders, attorneys, medical providers, and internal business partners throughout claim lifecycle to ensure clarity and prompt decision-making.
- Identified claims requiring additional investigation or specialized handling, coordinating with vendors and subject matter experts to enhance claim outcomes.
- Maintain quality standards while managing multiple claims simultaneously in a fast-paced remote environment.
- Mentor and provide guidance to claims associates regarding claim handling procedures and best practices.
Patient Account Manager
United Biosource Corporation
04.2010 - 07.2022
- Verified insurance eligibility and benefits to determine coverage for specialty medications.
- Reviewed payer requirements and supporting documentation to facilitate accurate benefit determinations.
- Coordinated communication among providers, pharmacies, health plans, and patients to streamline access to specialty medications.
- Maintained HIPAA compliance while handling confidential patient information.
- Researched and resolved insurance issues to ensure timely patient access to therapy.
- Documented account activity and maintained accurate records across multiple systems to support efficient claims processing.
EPM Applications Specialist
SergeMD
Memphis
04.2009 - 04.2010
- Implemented and delivered training for medical practice management software, enhancing user proficiency in physician practices.
- Collaborated with customers and suppliers to establish and fulfill service expectations, ensuring client satisfaction.
- Collaborated with team members to achieve project goals; meet pre-determined project deadlines; communicate with clients.
- Created comprehensive training materials for EPM/EMR and ICS software systems, facilitating effective user onboarding.
Senior Claims Examiner
Pittman and Associates
Memphis
03.1999 - 04.2009
- Reviewed, analyzed, and adjudicated medical, dental, and vision claims in accordance with employer benefit plans and policy guidelines.
- Investigated claim documentation to assess eligibility, medical necessity, and coverage requirements, ensuring compliance with policies.
- Applied Medicare, Medicaid, and commercial insurance guidelines to ensure accurate reimbursement decisions.
- Communicated claim determinations to providers and members through clear written correspondence and concise telephone support, enhancing understanding of claims process.
- Researched complex claims, resolving eligibility and coverage discrepancies to facilitate accurate claim processing.
- Maintained productivity and quality metrics while processing high claim volumes.
Education
Healthcare Management -
Columbia Southern University
Orange, AL11-2019
Skills
- Legal negotiations
- Third-party claims management
- Auto injury claims expertise
- Medicaid and Medicare knowledge
- HIPAA compliance
- Case management skills
- Commercial payer relations
- Claims reimbursement processes
- Insurance eligibility verification
- Microsoft Office applications
- Pharmacy benefit management
- Communication skills
- Prior authorizations
- Collaboration skills
- Problem-solving resourcefulness
- Claims investigation
- Claims oversight
- Claims adjudication
- Benefit determination process
- Documentation review
- Benefit verification
- Claims evaluation
- Coverage determination
- Claim documentation
- Relationship management
- Multi-claim management
- Remote work
Metrics
- Managed Inventory of 200+ claims
- Maintained high accuracy while meeting production goals.
- Negotiate settlements with attorneys in various states
- Worked with multiple insurance carriers.
- Licensed in KY, LA, FL, TX, and NM
Timeline
Claims Specialist - Auto Injury Third Party Tier 2/3
State Farm
07.2022 - Current
Patient Account Manager
United Biosource Corporation
04.2010 - 07.2022
EPM Applications Specialist
SergeMD
04.2009 - 04.2010
Senior Claims Examiner
Pittman and Associates
03.1999 - 04.2009
Healthcare Management -
Columbia Southern University