Customer Service / File Clerk / Insurance Verification Clerk /
- CYNTHIA KING3310 SW 106th Ave • Beaverton, Oregon 97005971-217-2797 • email@example.com
LIABILITY CLAIMS ADJUSTER / AUDITOR / SUPERVISOR
Knowledgeable claims management professional with experience overseeing evaluation, negotiations, liability and settlements of complex claims. • Proven success in handling complex and challenging claim situations, with history of serving as in-house expert on managing expedited claims and appeals.• Skilled investigator with demonstrated expertise in conducting interpersonal interviews and developing solid documentation that easily withstands legal challenges.• Adept leader and manager with talent for hiring, training, mentoring, and motivating expert claims management teams.
Claim Processing, Evaluation & Approval • Claim Negotiations • Appeals Review & ResolutionGroup Insurance Contracts • Legal Interpretation • Performance Guarantee AuditsCorporate / Regulatory Standards Adherence • Complex Claim Settlements • Workflow StreamliningRecord & Documentation Management • Policy Enforcement • Procedure & Process ImprovementCross-Functional Leadership • Customer Relations • Employee Hiring, Training, & Management * HIPPA experienced * Dental Office Management
AETNA, INC., Portland, Oregon • 2001-2012
Senior Disability Claim Consultant (Auditor) 2003 -2012
Senior Technical Specialist (Auditor) [internal position name change to above] 2003 -2012
Disability Claim Auditor [internal position name change to above ] 2003 -2012
Lead in developing and implementing proactive claim management strategies targeting company’s most complex, high-liability disability claims. Leverage knowledge and personnel resources across multi-functional teams, departments, and offices to assure prompt resolution and top-level service to Aetna customers. Assume final signoff responsibility for approvals and denials of LTD claims. Assemble and utilize clinical, peer review, IME / FCE / HA, Voc / Rehab, CCIU, Forensic CPA, and SS Vendor resources. Review claims to assure financial accuracy, compliance with policy provisions and contract interpretation, and to determine quality / content of documentation. Conduct performance guarantee audits, and focused reviews. Stepped in to provide coaching and mentorship to Disability Benefit Managers within LTD organization and identify large-scale training opportunities. In depth knowledge of HIPPA regulations. Extensive experience in medical records request and review. • Established reputation as go-to subject matter expert regarding all aspects and trends relating to LTD claims administration.• Led in developing departmental culture dedicated to outstanding performance, with focus on meeting operational business goals and assuring timely resolution of all claims. • Assessed claim management processes and implemented ongoing improvement strategies.• Played key role in reducing time required to transition STD claims to LTD analysts, as well as policies and procedures for investigating pre-existing conditions on STD claims.• Raised successful full-time return-to-work status to 10% of active claims through close cooperation with designated VRC to determine claimants’ return-to-work potential. • Introduced key procedure informing claimants about Vocational Rehab programs in approval letters and other important phrasing later adopted as company-wide standard.
Senior Technical Specialist (Assistant Team Leader) 2002-2003
Conducted up-front analysis of policy, system and regulatory changes to manage impact and interdependence. Focused on diverse constituent needs and found ways to adapt internal processes to meet those needs. Utilized all available applications to locate difficult or hard to find information when needed for constituents. Implemented and validated improvements to work processes. Advised others in prioritizing work. Drove a culture of engagement. Regularly solicited employee feedback and took action based on that feedback. Initiated and established policies that fostered diversity at all levels. Invested in the development of people as key components of increased competitiveness. Promoted a culture of energy and commitment that stretched people to excel. Provided people with the access and visibility required to excel. Effectively identified the people and tasks required to accomplish business goals. Created and promoted an uncompromising ethical culture. Held people accountable for fulfilling commitments, acting with integrity and remaining vigilant/raising concerns appropriately. Rewarded behavior that models compliance as a core competency. Managed set up and troubleshooting for complicated services and products. Problem-solved complex and atypical situations with constituents. Worked across the system to resolve service and contract conflicts. Supervised and coordinated activities of team members engaged in examining insurance claims for payment. Prepared regular periodic reports, and reviewed/monitored system reports to ensure adherence to corporate and regulatory standards within established guidelines. Participated in the specialized training and handling of complex claim situations and projects requiring advanced claim knowledge and experience, as delegated by Claims Manager and/or Director. Assigned claims/work loads of team members. Assisted team members on complex claims and helped ensure quality, production standards and specifications. I helped establish the process of transitioning STD claims to the LTD analyst timely, and trained the Claim Tech on the process. I was also a member of a team that wrote the Policies & Procedures for Pre-existing condition investigations on STD claims.
Long Term Disability Claim Analyst 2001-2002
Managed an inventory of Long Term Disability claims, evaluating compensability/liability. Investigated new claims by reviewing first reports of loss and supporting materials to determine the best initial contact; communicated with claimant, policyholders/customers; conducted in depth telephone interviews. Set up IME's and FCE’s. Interacted with policyholders, appraisers, attorneys and other third parties throughout the claims management process. Established action plans based on case facts, best practices, protocols, regulatory issues and available resources. Negotiated settlement within authority limits; escalated to team manager as appropriate. Appropriated utilization of ancillary resources including: Clinical, Peer Review, IME / FCE / HA, Voc/Rehab, CCIU, Forensic CPA, and SS Vendor resources. In my role as a Disability Claims Analyst, I worked closely with a designated VRC determining a claimant’s return to work potential, resulting in successful full time return to work on 10% of my active claims. Furthermore, I instituted the procedure of informing the claimant about Voc Rehab services in the approval letter. Of note, this procedure is now a standard in all Aetna approval letters. Additionally, excerpts from the custom letters I created in managing my LTD Disability claims have become standard language in the approved letter system at Aetna.
ASSOCIATED ADMINISTRATORS, INC., (TPA) Portland, Oregon • 1991-2001
Long Term Disability Team Leader 1999-2001
Coordinated hiring and training of new employees while cooperating with management-level staff to assure compliance with contracts and regulations. Managed appealed claims process. • Stepped in to manage escalated claim issues and negotiate settlements via phone, and administered subrogation. • Established reputation for outstanding management of company’s most challenging claims.• Conducted in-depth investigations and developed detailed documentation proven to stand up in court in case of legal challenges.
Life and Disability Claim Analyst 1993-1998
Managed an inventory of Long Term Disability claims, evaluating compensability/liability. Investigated new claims by reviewing first reports of loss and supporting materials to determine the best initial contact; communicated with claimant, policyholders/customers; conducted in depth telephone interviews. Set up IME's and FCE’s. Interacted with policyholders, appraisers, attorneys and other third parties throughout the claims management process. Established action plans based on case facts, best practices, protocols, regulatory issues and available resources. Negotiated settlement within authority limits; escalated to team manager as appropriate. Appropriated utilization of ancillary resources including: Clinical, Peer Review, IME / FCE / HA, Voc/Rehab, CCIU, Forensic CPA, and SS Vendor resources. Adjudicated all aspects of Life and Accidental Death claims; involving claim work up, investigation, reviewing for additional indemnity benefits, reviewing police reports, calculated and paid interest payments, requested and reviewed conservatorship and guardianship documents, requested and reviewed Power of Attorney documents. Wrote custom letters on all claims.
Customer Service Representative 1991-1992
Handled incoming calls providing benefit information and enrollment information/status. Managed dependent student enrollment verification info. Data entry of new enrollees. Problem solved issues [such as determining why a claim was not paid, providing appeal processes, and correcting minor claim errors]. Provided eligibility information to enrollees, providers and hospitals. Conducted and documented dental pre-authorizations.
Associate of Arts San Jose City College, San Jose, California
Licensed Life & Health Insurance Agent in Oregon and Washington