Management Life Insurance

Phone: 219-***-**** - home

Alt. Phone: 708-***-**** - cell.

E-mail ************@*******.***

**** ****** ******

Gary, IN 46404

Sheila M. Rayford

Objective To secure a professional level position utilizing my broad background in understanding all aspects of Disability,

Disease/Risk management, and Group Health Insurance concepts in the administration of benefits based upon

plan entitlement criteria.

Clinical Review Coordinator: compare charge detail to medical records for accuracy and standard of care;

serve as coding/compliance resource; DRG coding audits; detection of fraudulent billing practices of providers;

Functional

resolve provider disputes in Modifier-26 and R&C appeal actions;

summary

Account Executive: active participant in new account acquisition and implementation process; management of

client relationships; presentation of benefit and wellness programs to achieve health & wellness strategies;

internal office communications on sold case new client implementation; preparation of Administrative Service

Agreements;

Shock Loss Coordinator: prepare disclosure materials including large case potential notifications, Aggregate

reporting for Underwriting during contract renewal and prospect consideration ; laser and rate negotiations;

monitor & management of patient recertification; recommendation and management of large case management

candidates for cost containment

Disability Claim Specialist: Over 7 years of claims adjudication of group, insured and self-insured disability

claims; contribute to employer profitability through rigorous risk management of claims varying in levels of

complexity; investigation and analysis of patient information pertaining to medical condition, occupational

demands and plan provisions for benefit entitlement and payment recommendations; facilitate return work

transitions; explain benefit plan and entitlement criteria; .provided technical interpretations on contract

provisions, amendments, benefit calculations and plan requirements

Employment 2003 – 2009 Benefit Administrative Systems Homewood, IL

Clinical Review Coordinator

2001 -2002 CHD Meridian Healthcare Gary, IN

Medical Records/Scheduling Clerk

2001 - 2001 Professional Staffing Services Algonquin, IL

Sr. Claims Adjustor (Temporary)

1998 – 1999 Sedgwick Claims Management Services Chicago, IL

Sr. Disability Case Manager

1993 – 1996 UNUM Life Insurance Company Chicago, IL

Disability Benefits Technician

Education 2009 – present Trinity International University Dolton, IL

Business Administration/Psychology Double Major

1988 – 1989 DePaul University Chicago, IL

Liberal Arts and Sciences Major

Accreditations Certified in Medical Terminology (Dean Vaughn); Certified in through UNUM Life Insurance training course

Proficiencies/ Windows XP; working knowledge of ICD8/9-CM; knowledge of billing claim forms, including UB-92; Ingenix;

Expertise Benefit Informatics; proficient knowledge of MS Office Suite (Word, Excel, PowerPoint, Access, Outlook);

working knowledge of HIPPA, FMLA, COBRA and guidelines and regulations

References Available upon request

Contact this candidate