Johnathan Wallace
Atlanta
Summary
Dynamic Claims Specialist with extensive experience at Progressive, excelling in claims analysis and compliance management. Proven ability to evaluate complex claims, ensuring accurate coverage assessments and settlement determinations. Strong verbal communication skills complemented by expertise in Microsoft Office, fostering collaboration and mentoring junior staff to enhance team performance.
Overview
17
17
years of professional experience
Work History
Claims Specialist
Progressive
06.2018 - Current
- Evaluated accident details and insurance policies to identify coverage and liability.
- Gathering information through interviews with claimants, witnesses, and other relevant parties, as well as reviewing police reports and other documentation
- While much of the work is done independently, teamwork and collaboration are also important.
- While much of the work is done independently, teamwork and collaboration are also important.
Senior Claims Benefit Specialist
CVS
06.2008 - 07.2017
- Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
- Applies medical necessity guidelines, determines coverage, completes eligibility verification, identifies discrepancies, and applies all cost containment. measures to assist in the claim adjudication process.
- Handles phone and written inquiries related to requests for pre-approval/pre-authorization,reconsiderations, or appeals.
- Insures all compliance requirements are satisfied and all payments are made against company practices and procedures.
- Identifies and reports possible claim overpayments, underpayments and any other irregularities.
- Performs claim rework calculations.
- Distributes work assignment daily to junior staff.
- Trains and mentors claim benefit specialists.- Makes outbound calls to obtain required information for claim or reconsideration.
Education
Frederick Douglass, High School
Atlanta, GA2008
Skills
- Claims
- Claims processing
- Claims investigation
- Verbal communication
- Microsoft office
- Coverage assessments
- Settlement determinations
- Compliance management
- Policy interpretation
- Claims analysis
- Documentation review
Timeline
Claims Specialist
Progressive
06.2018 - Current
Senior Claims Benefit Specialist
CVS
06.2008 - 07.2017
Frederick Douglass, High School
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