Disability Case Manager Resume

SUMMARY:

Proficient in Guidewire Claim Center program.
Microsoft Word and Windows and Excel, Office XP and Lotus Notes.
Multi - task oriented.
Motivated self-starter.
Works well independently as well as a part of a team.
Experienced with general office duties, such as typing, filing, faxing and copying as well as experience caring for patients.
Enhanced skills in mainta'ining accurate patient files and charts. Improved proficiency with Billing and Coding using ICD9 and CPT4 codes.
Established skills in using the Medical Manager Program.

EXPERIENCE:

Confidential

Disability Case Manager

Responsibilities:

Reviews and evaluates new and ongoing STD claims to determine liability, giving consideration to contract provisions and medical/vocational information.
Verify eligibility.
Calculate claim payments.
Makes calls to Employers, Employees and Physicians to verify pertinent claim information.
Review medical to support disability.
Investigates any questionable aspects of claims, determines need for additional medical information and performs periodic medical updates to assess disability or return to work potential.
Approve or deny claims as required.
Draft approval or denial letters as appropriate.
Makes accurate, timely decisions on claims based on contract/plan provisions.

Confidential

Business Project Analyst

Responsibilities:

Defines, develops and provides information and analysis to drive the decision-making process and support business operations for internal and external customers.
May assist with researching, analyzing and recommending operational policies/processes/ procedures to standardize and develop best practices for the organization.
Skills critical to this career path include project management, leadership, and business expertise.
Tactical focus, expertise in at least one business process area, works with guidance to scope, plan and manage small-scale, department projects

Confidential

Data Entry Specialist

Responsibilities:

Sort incoming faxes, electronic mail and web inquiries to correct departments for processing.
Determines if incoming claims should go to Correspondence, Customer Service, Enrollment or Appeals Departments.
High volume production environment.

Confidential

International Provider Analyst

Responsibilities:

Updated International provider contracts after companies merge.
Loaded international providers into the system for employees that had medical treatment outside the country.
Followed specific government guidelines.
Loaded banking information for payments.
Successfully performed special projects with specified timelines.

Confidential

Disability Claims Manager

Responsibilities:

Verify eligibility.
Calculate claim payments.
Makes calls to Employers, Employees and Physicians to verify pertinent claim information.
Review medical to support disability.
Investigates any questionable aspects of claims, determines need for additional medical information and performs periodic medical updates to assess disability or return to work potential. Approve or deny claims as required.
Draft approval or denial letters as appropriate.

Confidential

Equipment Breakdown Claims Adjuster

Responsibilities:

Confidential

Disability Claim Processor

Responsibilities:

Makes pro-active contacts to claimants, physicians and/or employers to discuss various aspects of a claim as needed.
Investigates any questionable aspects of claims, determines need for additional medical information and performs periodic medical updates to assess disability or return to work potential.
Promptly responds to telephone and written inquiries from claimants, attorneys, physicians and policyholders while maintaining favorable rapport with internal and external customers.
Reviews and evaluates new and ongoing STD claims to determine liability, giving consideration to contract provisions and medical/vocational information.
Makes accurate, timely decisions on claims based on contract/plan provisions.

Confidential

Claims Adjudicator

Responsibilities:

Processed claims into a proprietary computer system and matches claim data with the appropriate authorizations
Determines correct claims payment or denial
Identifies and elevates questionable claims and authorizations or system issues as appropriate
Reviews plans, eligibility, patient notes, and authorizations to determine appropriate adjudication.
Creates authorizations when necessary based on individual provider and carrier contracts