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Manager Medical/ Claims Auditor

Philadelphia, Pennsylvania, United States
January 03, 2018

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Niambi Burton

Medical Stop Loss Auditor/Claims Trainer/Department Lead Manager

Philadelphia, PA 19120 - 267-***-****

Driven Medical Stop Loss Auditor/Claims Trainer/Department Lead Manager with 12 years of experience within all aspects of High Level Claims Management. Highly trained and experienced in Medical Stop Loss Insurance Claims, auditing, reimbursement, and negotiation skills with clients, and or vendors to maintain, and achieve quality assurance that will favorably affect the entire block of business. Willing to relocate: Anywhere

Authorized to work in the US for any employer


Senior Vice President of Claims/Department Lead Manager Underwriting Management Experts - Lansdale, PA - January 2015 to December 2016 Level Funded Claims Auditor

Medical Stop Loss - North Wales, PA - March 2010 to January 2015 Served as subject matter expert in Level Funded weekly, monthly, and end of policy year auditing, auditing of Medical Stop Loss Traditional, and Specific Claims.

● Reduced stop loss ratios through fair, and prompt processing of claims.

● Analyzed first reports of loss, and underlying file material to determine if a claim was reimbursable.

● Notified reinsurers of all high dollar claimants once contracted thresholds had been met, as well potential future high dollar claimants.

● Requested and recommended Cost Containment from vendors for all potential high dollar claimants.

● Completed month-end Specific and Aggregate reserves in database, and reported final reserve reports.

● Contacted third party administrators, reinsurers, medical vendors, and legal representatives to negotiate final settlements for claims.

● Obtained all necessary information to complete proper evaluation of injury claims.

● Investigated claims, conducted field audits, determined losses, and reported findings.

● Attended anti-fraud training classes.

● Investigated any potentially fraudulent claims with a focus on thoroughness, quality, and cost control.

● Created spreadsheets to improve claims management, and reporting accuracy.

● Mentored, and trained numerous new employees, as well as recently promoted employees of the claims staff.

● Calculated and verified Coordination of Benefits (COB).

● Received, audited, and approved signed plan documents for in force cases.

● Managed and conducted biweekly department meetings.

● Provided reporting for CEO and sales team on managing operations, and work flow.

● Knowledge of HIPAA Compliance Law.

● Completed proper email etiquette workshop.

● Completed Stop Loss 101 course.

Claims Coordinator

Montgomery Management Inc - North Wales, PA - February 2009 to March 2010 Verified and logged in deadlines for responding to daily inquiries.

● Maintained administrative, procedural processes to improve accuracy and efficiency.

● Handled weekly check runs for reimbursable claims, and mailed checks and EORs to Third Party Administrators.

● Received, audited, and approved Groups Signed Plan Documents. Underwriting Coordinator Director

Montgomery Management Inc - North Wales, PA - October 2005 to February 2009 Directed and coordinated department functions for a team of five employees.

● Standardized department filing system to increase efficiency.

● Verified and logged in deadlines for responding to daily inquiries. Data Entry Operator

PRWT Inc - Philadelphia, PA - March 1999 to October 2004 Verified that information in the computer system was up-to-date and accurate.

● Eliminated outdated records by sending the records to be scanned.

● Verified and logged in deadlines for responding to daily inquiries.

● Compiled statistical information for daily production reports.

● Entered City Philadelphia Moving Violations, Sweep Violations, and the Philadelphia Parking Authority parking tickets daily.

● Verified that previous entries were correct.



Community College of Philadelphia - Philadelphia, PA 1996 to 1997


Claims (7 years), Coaching (Less than 1 year), database (4 years), HIPAA (4 years), training (10+ years) ADDITIONAL INFORMATION

Skill Highlights

● Leadership/Communication Skills ● HIPAA Compliance

● Database Management ● CPT and HCPCS Coding

● Staff Development ● Cost Management

● Medical Coding ● Quality Management

● Knowledge of Medical Terminology ● Administrative Skills Core Accomplishments

● Created and launched a well-received department plan program to increase productivity.

● Promoted to manager of Claims Coordinators and training within 3 months of moving to the department.

● Promoted to Senior Claims Auditor within first month of launching Level Funded product; after six years with the MGU.

● Promoted to Senior Auditor of Level Funded Department within 3 Months of being promoted to Senior Claims Auditor.

● Promoted to Senior VP of Claims during the first year of MGU opening.

● Promoted to Department Lead within a year and a half of MGU opening.

● Participated and completed 9 month long Career/Life Coaching classes.

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