Destiny Alston
Durham
Summary
Claims specialist with over six years of experience in complex adjudication and training. Proven track record in enhancing operational efficiency, minimizing errors, ensuring compliance, and accuracy in claims management. Expertise in handling claims beyond specialist authority, applying medical necessity guidelines, and verifying eligibility. Proficient in pre-authorization requests, appeals, and identifying payment discrepancies, while mentoring junior staff, and supporting leadership with escalations.
Overview
13
13
years of professional experience
Work History
Claim Specialist
Aramark
Remote
01.2021 - 11.2025
- Reviewed 60-70 complex claims exceeding specialist adjudication authority, adjudicating in accordance with plan processing guidelines, while maintaining a 98.5% accuracy rate.
- Applied medical necessity guidelines to determine coverage, and completed eligibility verification using company-provided systems, improving claim payment accuracy by 15%.
- Identified and reported claim overpayments, underpayments, and processing irregularities to ensure compliance with company practices and procedures.
- Served as the first point of escalation for claim specialists, mentoring staff to resolve complex adjudication issues, and reducing rates by 7%.
- Conducted 50+ outbound calls daily to patients, providers, and health plans regarding pre-authorization, eligibility verification, and claim discrepancies impacting payment.
- Acted as a subject matter expert by responding to complex claim inquiries, and coaching specialists on claims handling processes.
Senior Claim Benefit Specialist
Acadia Healthcare
Remote
08.2013 - 11.2018
- Processed 75-100 medical claims daily in a high-volume production environment, while meeting quality and turnaround time standards.
- Completed coverage determination and eligibility verification in accordance with the plan processing guidelines, contributing to a 10% reduction in claims and processing delays.
- Handled inbound and outbound calls related to pre-authorization requests, claims status, and discrepancy resolution.
- Identified and reported claims overpayments, underpayments, and discrepancies for review.
Junior Claims Processor
Duke Health Center South Durham
South Durham
04.2013 - 11.2018
- Reviewed and processed 40 to 60 claims per day under established guidelines, while maintaining productivity and accuracy benchmarks.
- Assisted senior specialists with claims research and documentation, supporting the resolution of 20 or more complex claims weekly.
- Gathered the required information and escalated complex claims appropriately to support timely claim resolution.
- Met daily productivity and quality expectations in a fast-paced environment.
Education
High School Diploma -
East Chapel Hill High
06-2012
Skills
- Complex medical claims adjudication
- Medical necessity evaluation
- Determination and eligibility verification
- Pre-authorization, reconsideration, and appeals
- Overpayment and underpayment identification
- Subject matter expert (SME) support
- High-volume production environment
- Training and mentoring claims specialist
- Compliance auditing
- Claims
- Complex claims consulting
Timeline
Claim Specialist
Aramark
01.2021 - 11.2025
Senior Claim Benefit Specialist
Acadia Healthcare
08.2013 - 11.2018
Junior Claims Processor
Duke Health Center South Durham
04.2013 - 11.2018
High School Diploma -
East Chapel Hill High