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Click here or scroll down to respond to this candidateCandidate's Name
Fairview Heights, IL Street Address PHONE NUMBER AVAILABLE EMAIL AVAILABLEPROFESSIONAL SUMMARYExperienced Claims professional with 10+ years of experience in claims handling. I am looking to transition into a new career. I have extensive experience with training both subordinates and co-workers in system operations.SKILLSAccuracy & attention to detail, conflict management/dispute resolution, cultivating & managing relationships, data collection & maintaining records, communicating with all levels in the chain of command, remaining flexible and able to shift priorities as needs change. I am also able to work with colleagues and customers with multicultural backgrounds, treating each with dignity, equality and respect.CERTIFICATIONSAssociate in Claims (AIC) Issuing organization: Insurance Institute of America Associate in Insurance Services (AIS) Issuing organization: Insurance Institute of America Associate in General Insurance (AINS) - 21, 22, 23 & 24 Issuing organization: Insurance Institute of AmericaWORK EXPERIENCEInsurance Reviewer and Denials Analyst January 2021 Present Anderson Hospital, Maryville, ILReviews and analyzes unpaid aging non-government claims daily utilizing Meditech automated Tasks. Determines current account status. Follows up on payor websites or with payor customer service departments to determine payor status of claim adjudication. Provides necessary action steps to expedite claim payment by payor. Analyzes payor remittance advices to determine any needed action steps if partial payment is made by payor. Determines of other insurance payors must be billed in the correct coordination of benefit order. Escalates problem accounts to team or department leadership.Notify commercial collections supervisor of all other opportunities for improvement or reimbursement variance resolution. Identify opportunities for process improvement in Patient Financial Services or Patient Access.Reviews, analyzes, and takes appropriate actions on payor refund request letters related denial issues. Determines when to refund payors; authorize recoupments by payors; or appeal regarding disagreement with refund requests. Reviews, analyzes, and takes appropriate actions regarding payor denials, utilizing Denials Management in Meditech. Appeals denials whenever possible.General Liability Claims Adjuster November 2015 August 2020 Schnuck Markets, Inc. St. Louis, MOTrained and coached Store Managers on claims reporting and utilizing computer claims software.Adjusted general liability bodily injury and property damage claims, both litigated and non-litigated.Performed frequent cross-functional communication and collaboration with multiple departments; frequently worked with Legal Department to assist in handling litigated claims; led and participated in roundtables to determine resolution of complex claims.Collaborated with other internal departments to reduce occurrences of fraud, customer service issues and to improve customer relations; provided advanced negation and problem-solving solutions.Assisted team members with claims handling issues; provided alternative perspectives on handlingAssisted in selecting new claims software and trained employees on new software; frequently navigated different computer programs to effectively manage claim workload. Senior Claims Adjuster August 2006 May 2015Gallagher Basset Maryland Heights, MOHighest settlement was around $1M; amount of personally handled reserves was around$6M on average; trained and mentored adjusters who were new to the company.Responsible for investigating, evaluating, disposing and settling complex claims and high exposures with minimal supervision.Attended multiple mediations to resolve complex claims with legal involvement.Reported potentially fraudulent claims to SIU for further investigation, identified and pursued client subrogation recovery on eligible claims.Participated in, and led, client presentations on open claims to improve and update claim status; participated in peer roundtables to discuss alternative resolutions for more complex claims, including those with major bodily injuries. Workers Compensation Adjuster September 2004 June 2006 Florists' Mutual Insurance Company Edwardsville, ILResponsible for planning, recommending, reserving and executing investigations, valuations, dispositions, and settlements of multi-jurisdictional high exposure Workers Compensation claims.Investigated complex lost time Workers Compensation claims to determine compensability for multiple jurisdictions; evaluated, documented, and executed proper claim coverage; filed reinsurance reports on major loss claims.Managed and coordinated medical treatment, recovery, and return to work processes based on disability guidelines and projected target dates; calculated wages, documented disability, and paid benefits on time.Collaborated with medical providers, outside vendors and attorneys as needed. Communications Systems Radio Operations Supervisor (SSgt) United States Air Force Honorably Discharged VeteranShift supervisor responsible for leadership of staff, custody and control of classified materials and equipment. Writing of performance reports and mentorship of those charges under my direct supervision.Call Center Supervisor responsible for coordination of wartime running of switchboard operations and communications systems.EDUCATIONSouthern Illinois University Edwardsville - Edwardsville, IL Bachelor of Arts in Psychology and minor in Sociology. Graduated Cum Laude. |
