Delia Higgins

Managed end-to-end adjudication of 240+ active workers' compensation claims monthly across IL, NC, and KY, applying plan benefits and contractual reimbursement terms while complying with State and Federal WC regulations. Processed 65% of the caseload (156+ files) through active litigation and audited claim accuracy/completeness to drive remediation and process improvements.

Processed medical-only and lost-time workers' compensation claims across 18 jurisdictions, verifying eligibility/coverage and ensuring accurate documentation, coding, and adjudication per plan benefits and regulatory requirements. Audited claim files for coding compliance, handled indemnity payments and authorizations, and escalated complex matters for additional review.

Reviewed, evaluated, and adjudicated approximately 1,000 active personal injury cases by verifying coverage, assessing liability exposure, and finalizing determinations to meet contractual reimbursement terms and organizational policies. Developed desktop procedures and reported claim trends/inventory issues to improve consistency and resolution timeliness.

Audited provider billing submissions and claim documentation for coding accuracy, contractual reimbursement compliance, and remediation of defects. Built Excel-based tracking/reporting tools to monitor provider performance, claim compliance status, and workflow efficiency.

Performed internal compliance audits for newly onboarded assets, verifying documentation accuracy/completeness and identifying configuration/data deficiencies for reporting to senior leadership. Managed wealth management system updates (add/update/remove assets) and developed procedural documentation to support consistent audit-ready workflows.

Administered end-to-end adjudication of 200+ monthly prior authorization cases, processing per Medicare, Medicaid, and commercial payer guidelines and routing 35% to formal denial appeals while tracking 45% pending payer response and 20% awaiting complete documentation. Audited requests for coding/eligibility/documentation accuracy, applied COB rules, and maintained desktop procedures to ensure co

Owned customer claim intake end-to-end by processing and entering orders into claims/order management systems, verifying eligibility/coverage and documentation accuracy before handoff. De-escalated customer complaints and coordinated ATP and seating technician scheduling to maintain production quality and customer satisfaction.

Earned a Bachelor of Arts in Public Relations & Marketing from Ashford University, graduating in October 2018.