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Medical Customer Service

Location:
Cleveland, OH
Posted:
April 23, 2014

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Resume:

CAREER Success oriented, with over ** years of exceptional

experience in claims representation.

SUMMARY: Looking for a career advancement to combine Workers

Compensation and claim handling skills obtained through on the job

assignments as well as advanced certifications. Having a strong

sense of responsibility, self-motivation and outstanding talents

for assessing client's needs, I'm an excellent team player, with

the ability to work independently, in a highly professional and

diplomatic manner to effectively communicate with all levels of

management.

WORK

EXPERIENCE:

CGI Federal

Cleveland, OH

Medical Claims Specialist

02/13- Present

*Follow up on Center for Medicare Service leads for claims

that should have been paid by another payer

* Confirm correct primary payer insurer for claim

* Initiate a demand process with insurance companies

including evaluation of beneficiary information.

* Track correspondence through to ensure timely response

within Service Level Agreements.

* Facilitate and document communication with both insurers

and employer groups.

* Provide accurate and timely responses to queries through

multiple comminication outlets.

* Escalate outlying queries that have unique circumstances

to supervisors in alignment with prescribed processes.

Baylor and Associates

Brecksville, OH

Claims Administrator

05/08 - 03/12

* Interpret and implement State of Ohio Law and Bureau of

Workers' Compensation (BWC) policies, to clients, to establish

claims.

* Process 1099 for Self-Insured employers.

* File SI-40 (Paid Compensation and Case Reserves) for Self-

Insured employers.

* Negotiate settlements with attorneys on Medical and Indemnity

claims.

- Ranging from $1000.00- $90,000.00

* Process Environmental Exposure Claims.

* Create Loss Run Reports to illustrate claim pay out amounts

and reserves for future cost.

* File court appeals to BWC, District and Staff Hearing

Officers.

* Schedule Independent Medical, Permanent Total Disability, 90-

Day and Percentage Partial Examinations.

* Pay compensation wages for Percentage Permanent Partial,

Temporary Total and Wage Loss Settlements.

* Prepare Medical Examination Letter for physicians.

* Review invoices of payment for Defense Medical.

* Input medical bills for payment into Medical Payment Systems.

* Established compensation checks drawn against awarded claims.

* Run and review audit reports for check runs.

* Create work file for check printing.

* Manage and referred compensation claims for Vocational

Rehabilitation.

* Implement reserves on compensation claims based on claim

allowance.

* Adjust reserves when unexpected treatments occur.

* Report catastrophic claim to excess insurance carrier.

* Reduce reimbursement fee bills in accordance to the BWC Fee

Schedule.

* Process and forward Certification and Denial Correspondence.

Kelly Services

Record Acquisition Coordinator

Mayfield Hts., OH

Assignment: Litigation Management Inc.

02/07 - 11/07

* Contact various medical facilities, government agencies,

insurance companies, personnel departments, educational

facilities, and the military to obtain necessary medical and

non-medical records.

* Identify medical providers from legal documents, the

internet and other resources.

* Generate request letters and initiate follow up telephone

calls.

* Review records received to ensure the completeness.

* Obtain pathology/radiology inventories.

* Working knowledge of medical terminology.

1-888-OhioComp

Cleveland, OH

Workers' Comp. Claims Specialist

07/06 - 12/06

* Contact providers for medical documentation

* Process initial injury reports

* Verify and resolve appropriateness of medical

treatment and charges.

* Gather information to develop, negotiate and

implement return-to-work plans.

* Managed on the job injury reports

* Process new worker compensation injury claims

* Enter all work data into claim system

* Follow-up with injured worker for claim

information

Insurance Overload Systems Cleveland, OH

Workers' Comp. Claims Representative

Assignment: St. Pauls Travelers

04/06 - 05/06

Assignment: GAB Robbins 05/05

- 09/05

Assignment: Specialty Risk Service

07/04 - 01/05

* Communicate with outside workers'

compensation representatives to ensure timely

processing and response.

* Conduct medical inquires with doctors to obtain

information to accurately assess claims.

* Perform claim maintenance and establish contact

with all interested parties.

Brown and Margolius Law Offices

Cleveland, OH

Claims Assistance

10/03 - 02/04

Temporary Contract

* Analyze files and applications for proper

adjustments.

* Process 1st report of injury forms and document

all medical claims and forms.

* Forward legal documentation and representation on behalf

of clients.

Bureau of Workers' Compensation Cleveland,

OH

Customer Service Specialist

03/79 - 02/02

* Change Caseload of Workers' Compensation Lost-Time

Disability Claims.

* Make decisions for claims to survivors of the deceased covered

workers who are entitled to file claims for survivor benefits.

* Verify and resolve appropriateness of medical

treatment and charges.

* Gather information to develop, negotiate and

implement return to-work plans.

* Examine illness and survivor claims.

* Research, and authorize, negotiate, and issues

settlement of claim.

* Conduct field inquires required to obtain

information to accurately assess claim.

* Resolve disputed issues to determine compensation

and appropriate benefit level.

* Identify and refer cases to fraud.

* Establish and maintain contact with all

interested parties.

* Document all claim transactions and activity in

claims diary system.

* Complete progress reports and prepares claims for

hearings with Industrial Commission.



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