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I am actively seeking a long term position which would allow me to use my skills
in the field of insurance by sharing my knowledge with others and to continue t
o grow and learn with new work experiences. I am a very dedicated individual wit
h good work ethics.
Career Summary:
Thirty six (36) years of experience in processing medical and dental claims for
large self-funded and risk groups along with Medicare.
Extensive knowledge of Medical Terminology including CPT codes – procedural terminol
ogy, ICD-9- description of diseases, HCPCS codes –Medicare Level II codes. Includi
ng knowledge of ADA codes for dental services.
Work Experience:
1996-July 1, 2009 Coventry Health Care, Inc Formally First Hea
lth (Houston, Texas)
Supervised an organized team of cross-functional team members to meet or exceed
service requirements. Managed staff development and work standards. Knowledge
of health care products under fully insured and self-funded with the ability to
maintain production levels and quality goals. Supervised member service employ
ees.
Identify and implement process improvements, encourages ownership of and group p
articipation in the improvement initiatives.
Examine and analyzes the team’s performance against measured service operation goals
, demonstrate ownership for overall team results, recommend and lead the impleme
ntation of plan(s) action to improve the team’s service level.
* Investigate, evaluate and settle claims, applying technical knowledge and huma
n relations skills to effect fair and prompt disposal of cases and to contribute
to a reduced loss ratio.
* Adjust reserves or provide reserve recommendations to ensure that reserve acti
vities are consistent with corporate policies.
* Resolve complex, severe exposure claims, using high service oriented file hand
ling.
* Maintain claim files such as records of settled claims and an inventory of cla
ims requiring detailed analysis.
* Verify and analyze data used in settling claims to ensure that claims are vali
d and that settlements are made according to company practices and procedures.
* Examine claims investigated by insurance adjusters, further investigating ques
tionable claims to determine whether to authorize payments.
* Contact or interview claimants, doctors, medical specialists, or employers to
get additional information.
* Confer with legal counsel on claims requiring litigation.
* Supervise claims adjusters to ensure that adjusters have followed proper metho
ds.
Computer Skills:
MS Office (Word, Excel, PowerPoint, Outlook, IDX. Direct Provider.com, Microsof
t Access, Avaya. CEI-COB, CBSA-Flex, Pend Database, Workflow, ADP-Payroll, Novel
l, Comp-Net, People-safe, Web-apps, OneSource, Internal Audit database. MS-DOS.
Education:
Graduate of M.B. Smiley High School (Houston, Texas)
Microsoft Excel 2003
Microsoft Access 2003
Footprints: Leaders guide to Respecting Others
Leadership: Conducting Effective Focal Reviews
Completed Corrective Action Course
Completed Performance Coaching Course
References available upon request.