Yyyyyy x. yyyyyy
Highly Experienced Insurance and Medical Industry Professional with a diverse background in Claims Adjustment and Medical Office Management. Expertise in workers compensation, auto casualty claims, insurance billing and investigative techniques. Seeking Senior Level Claims Adjustor position with an organization that values broad based experience, leadership and dedication to customer service.
Auto Casualty Adjuster/P & C License
Benefit Analysis and Medical Coding
CPT, ICD-9 and Claims Processing
Excellent Communication Skills
Insurance Billing, Medical Fraud Recovery
Insurance Contract Interpretation/Negotiation
Medical Office Management, Case Management
Surgical Procedure Coding/Investigation for TPL
Third Party Liability, HMO, PPO, Self Funded Claims
Anatomy/Surgical Procedure Review
Workers Compensation Medical Adjuster
DeVry University, Colorado Springs, Co - BA, Business Management, Minor in Medical Administration
Sinclair Community College, Dayton, OH - Nursing and Business Management
Montgomery County Joint Vocational School - Medical Secretary and Medical Assisting Course, Certified MA;
Allstate Tech-Cor - Bodily Injury Adjusting training course,
P & C Producer License for the State of Colorado (expiration, June 20, 2009)
Health Solutions (2006 to Present)
Claims Adjuster/Provider Relations
w Review and adjudicate self-insured claims to ensure proper claims processing for individual employer contracts; review contract language and ICD 9 and CPT codes to determine if they are payable under the contract, pre-existing conditions are reviewed and processed per contract.
w Handle all insurance broker inquiries with 24 hours, manage complaint procedures and release information in compliance with HIPPA regulations.
w Work with clients to explain situation regarding investigations pertaining to pre-existing conditions.
w Received award for Exceptional Customer Service and achieved 98.7% accuracy for adjudicated claims.
(2003 to 2004)
w Created loss reports, confirmed coverage and explained plan procedures regarding auto injury claims and physical damage upon customer inquiry.
w Investigated policy coverage and liability exposures for medical injuries and property damages.
w Evaluated legal liability, jurisdiction and injuries to determine applicable settlement value or denial of claim; incorporated alternative dispute resolution to settle claims.
w Evaluated and negotiated settlements of first and third party injury and physical damage, communicated with plaintiff attorneys regarding damage, liability, coverage documentation and final settlements and delivered information and follow up in a timely manner to ensure compliance with time limit demands.
w Received multiple awards for outstanding customer service and maintained a 90% ratio of non-litigated settled files.
Insurance Company (2001 to 2003)
w Investigated auto claims involving moderate to severe first and third party bodily injury and physical damage.
w Created loss reports, recorded statements, confirmed coverage and answered customer inquiries regarding claim procedures.
w Investigated legal liability and evaluated complex medical records and history to make recommendations for equitable claim settlement.
w Achieved front line adjuster status; settled claims within the first 90 days and maintained a departmental goal of of 92% of fast-track settlements.
w Received multiple awards and commendations for outstanding customer service and advanced knowledge of medical terminology and anatomy.
Overload Systems (2000 to 2001)
Medical Desk Workers' Compensation Adjuster (Temporary Position)
w Performed duties related to medical adjuster position; adjusted moderate workers compensation claims, gathered injury information, evaluated company s liability, confirmed coverage and opened appropriate reserves.
w Interacted with clients to explain claim procedures, reviewed medical records and incoming claims and arranged for payment processing.
w Assisted senior adjustor in evaluating complex medical files; utilized in-depth medical terminology, surgical procedure review and anatomy to evaluate higher profile claims.
w Provided administration assistance to litigation specialists as needed.
Temp Service, contract, US Postal Service (2000)
Workers' Compensation Duplicate Payment Recovery (Short Term Contract)
w Led investigations to uncover overpayment and/or duplicate payment for Workers' Compensation claims; evaluated services for claimants to ensure that payment were correct and in accordance with agreed terms.
cases to ensure that all duplicate payments were paid back in full to the US
Evaluated complex medical procedures documentation to ensure that there was no subrogation of services.
Medical Collector Pikes Peak Pain Professionals Colorado Springs, CO
1996-1998 Customer Services FHP Health Care/Pacificare HealthPlan Colorado Springs, CO
1995-1996 Claims Analyst - Coder Claims Overload Systems (Temp Service) Denver, CO
1993-1994 Claims Analyst & Support Sharp Healthcare San Diego, CA
1988-1990 Medical Assistant Health Maintenance Plan Dayton, OH
1986-1987 Office Manager Belmont Family Clinic Dayton, OH
1985-1986 Medical Assistant Morton Levine, DPM Dayton, OH
RIMS, Iliad, 2003 MS Office -Word, PowerPoint, Excel, 2003 Microsoft Access Data Base, Medical Manager
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