PORCHIA DARBY
Lithonia
Summary
Claims Analyst with a strong background in medical claims processing and third-party liability. Effective at negotiating settlements, analyzing claim errors, and implementing corrective measures to enhance overall claims efficiency and accuracy.
Overview
10
10
years of professional experience
Work History
Part time-Claims Adjuster
Epiq Systems
09.2025 - 01.2026
- Managed third-party liability claims
- Determined fault and degree of negligence according to state/local jurisdiction laws and policy contracts, ensuring compliance and accurate claim processing.
- Reviewed medical records, bills, and repair estimates to assess true value of bodily injury or property losses; negotiated settlement amounts with claimants and legal counsel, authorizing payouts.
- Handle class action settlements
- Investigating coverage to establish which insurance is primary
- Managed auto insurance, workers' compensation, and bodily injury claims, facilitating resolution and supporting client needs.
Claims Analyst/Dispute Analyst
COGNIZANT
Wisconsin Rapids
11.2024 - 11.2025
- Reviewed and adjudicated medical claims to ensure accuracy, completeness, and compliance with payer policies.
- Analyzed claim discrepancies, payment variances, and denials to determine appropriate resolution.
- Processed claim adjustments, corrections, and reprocessing requests to ensure timely resolution.
- Investigate and verify information using ISO claim search
- Conducted coordination of benefits investigations to verify coverage details.
- Maintained detailed claim documentation and audit-ready records for effective quality assurance.
- Conducted audits of processed claims to uphold compliance with quality assurance standards.
- Process claims with QNXT, Trizetto and Facets
Grievance Appeals & Claims Specialist
CVS/AETNA
Decatur
10.2021 - 11.2024
- Reviewed and processed medical claims and appeals, ensuring accurate adjudication and timely payment.
- Evaluated CMS-1500 claim forms and EOBs, resolving auto-adjudication and payment issues.
- Identified claim errors related to coding, eligibility, and benefits, implementing corrective actions.
- Collaborated with internal teams to resolve complex claims, preventing processing delays.
Auto/Medical Claim Specialist
WPS HEALTH SOLUTION
Decatur
03.2016 - 10.2021
- Evaluated auto claims for accuracy and completeness.
- Resolved complex claims involving COB, appeals, denials, and payment discrepancies.
- Analyzed medical claims for coverage determination, benefit application, and payment accuracy.
- Utilized Facets and Mainframe systems to research and process pending claims, ensuring timely follow-up and resolution.
- Ensured compliance with regulatory requirements and internal claims processing standards.
- Coordinated with medical providers to gather essential claim information, facilitating accurate claims processing.
- Managed claims processing for workers' compensation cases efficiently.
- Reviewed insurance policies to determine coverage limits.
- Collaborated with repair shops to assess vehicle damage, supporting effective claims evaluations.
Education
High School Diploma -
Gateway Christian School
Horn Lake, MS05-2010
Skills
- Medical Claims Processing
- Medicaid, Medicare and or government payer claims experience
- Government payer claims
- Claims Adjustments
- EOB Review
- QNXT Processing
- Facets
- Third Party and workers compensation
- Dental Grievances and appeals
- Workers compensation claims
- Litigation Support
- Healthcare Appeals
- CMS-1500 & UB04
- Claims adjustment
- ISO claim search
- Mainframe Systems
- Data Entry
- CRM & Salesforce
- Problem-solving
- Negotiation techniques
- Caseload management
- Insurance regulations
- Adjuster Systems
- Caseload management
- Negotiation techniques
Timeline
Part time-Claims Adjuster
Epiq Systems
09.2025 - 01.2026
Claims Analyst/Dispute Analyst
COGNIZANT
11.2024 - 11.2025
Grievance Appeals & Claims Specialist
CVS/AETNA
10.2021 - 11.2024
Auto/Medical Claim Specialist
WPS HEALTH SOLUTION
03.2016 - 10.2021
High School Diploma -
Gateway Christian School