Customer Service Manager
Resume:
Karen L. Miller
Columbus, Ohio 43228
*********@*****.*** * 614-***-****
Work Experience
Sedgwick 4/2008 to 3/29/2019
Hilliard, Ohio 43026
Team Lead (1/2014-3/2019)
Claims Examiner (4/2008-12/31/2014)
(800) 267- 4001, Mary Heineman or Thomas Gulla
Team Lead Workers’ Compensation Self Insured Ohio (Indiana and Kentucky): Supervised a staff of 5-7 including hiring, training, discipline, development and performance reviews. Responsibilities also included balancing adjuster caseloads, managing reports (SI40, BWC audit responses and internal reports), evaluating claim financials, claim triage and regular ongoing claim oversight to ensure claim requirements are met according to Sedgwick best practices, legal applications, state guidelines, and/or client service instructions. We worked closely with employers, attorneys and the states to ensure programs ran smoothly.
Claims Examiner: Case Load was 160- 195 active lost time claims for Ohio, Kentucky and Indiana employers. Responsibilities included investigation, paying compensation, claim reviews, hearing preparation, coordinating medical management, daily task management, completion of EDI or state forms filing, evaluating settlements and other claim management activity. Requirements were set for adhering to all state, company, employer and legal guidelines. This required working with the employer, injured parties, state entities and legal representatives to ensure files were moving toward resolution timely and aggressively when appropriate.
Cambridge Integrated Services Group 11/1/06 to 4/2008
300 W Wilson Bridge Rd., Suite 220
Worthington, Ohio 43085
Hearing Rep./Coordinator & Account Manager
No longer in business, Thomas Gulla or Sherm Caldwell
Hearing Rep. & Coordinator: Upon the transition to Cambridge, responsibilities included developments of the Ohio hearing process and procedures. Constructed the Cambridge docket and invoicing tracking system, coordinated attorney and sub-contractors for hearing attendance. Attended hearings in all locations as needed. Work closely with vendors, attorneys, adjustors, BWC/Industrial Commission and employers to ensure hearing attendance, file preparation and follow up are monitored so that appropriate documentation is available and filed appropriately.
Account Manager: Responsibilities include monitoring of 22 accounts. Involved in the timely completion of renewals, excess reinsurance, tracking and resolution of operations or service related issues. Monitor and send out client ad hoc reports or jurisdictional required reports as well as educate clients on system access to enable them to access their claim information. Also attend and coordinate claim reviews, file audits and program reviews. Additional responsibilities include filing AC2’s, SI40’s, input for RFP’s and lending assistance to team members in their absence to ensure clients needs are addressed.
Gates McDonald 2/2003 to 10/31/06
215 N Front Street
Columbus, Ohio 43215
Claim Representative (2/03 to11/05)
Sr. Claim Representative (11/05 to 4/05)
Supervisor (4/05 to 10/31/06)
(614) 582 - 7468, Thomas Gulla
WC Claim Supervisor: Responsibilities include supervising a staff of 8-10 people, review/monitoring new and open claims, reports and ongoing development of the staff while adhering to state, company and contract standards/procedures. Jurisdictional experience is primarily Ohio Self-insured but includes knowledge of Michigan, West Virginia, Kentucky and Indiana Self-insured and Insured programs.
WC Claim Rep/Sr. Claim Rep.: Handled a case load of 180-200 lost time claims, primarily on previously problem accounts. Responsibilities included timely initial investigation of new claims, monitoring diaries, reports, reserves and compensation on open claims. Monitored and referred files for medical exams and litigation. Also completed reserve and claim reviews with various employers and assisted with the assignment of new claims in the supervisors’ absence. Worked closely with the employers, Attorney’s and injured worker’s to ensure a timely, cost effective and care conscious resolution of Worker’s Compensation claims.
Eastland Chiropractic/Chiro. Physicians of Columbus 04/02 to 12/02
4261 Kimberly Parkway
Columbus, Ohio 43232
Billing Specialist
614-***-****, Kimberlee Stover
Billing: Responsible for printing and sending out HCFA1500 bills, following up on all workers’ compensation, insurance and personal injury outstanding balances. Posted payments in Medisoft and reconciled account balances. Responsibilities included auditing and addressing approved or denied C9’s for authorization and submitting required documentation. Maintained relationships with patients, Attorney’s and MCO’s/TPA’s. Completed medical evaluations and worked with the office staff to complete any tasks that require assistance (front desk, therapy, receipts, ect…)
Aetna US Healthcare 05/00 to 04/02
7400 W. Campus Road
New Albany, Ohio 43054
Customer Service Representative (05/00 to 10/01)
Service Consultant (10/01 to 4/2002)
614-***-****, Shari Maidel
Customer Service: Responsible for answering incoming phone calls from members/providers and helping resolve issues with their healthcare benefits. Reviewed claims that had been processed, calculate negotiated/prevailing fees and read/interpret contracts with precision. Maintain accuracy when quoting benefits and managed call time and abandon rates. Verified COB (coordination of benefits) information.
Service Consultant: In addition to all of the above responsibilities, this position included processing, paying and adjusting claims to allow for first call resolution and prevents call backs since all functions could be resolved by one person.
McGraw Hill 11/99 to 5/00
860 Taylor Station Road
Blacklick, OH 43004
Customer Service Representative
614-***-****, Karen Krsak
Responsible for taking incoming calls and resolving issues involving book orders. Traced packages through UPS and other mail carriers. Flannery and La Salle account specialist/ manager. Controlled and maintained incoming/outgoing pick up orders. Reviewed ISBN (international book number) errors.
Simon Compensation Services, Inc. 3/99 to 11/99
30 Northwoods Blvd
Columbus, Ohio 43235
BWC Claims adjuster/Reviewer
614-***-****, Terry Johnson
Responsible for all functions regarding Ohio Bureau of Worker’s Compensation claims for Kmart’s state fund program. This included reviewing incoming bills, creating checks for compensation and medical care, dealing with providers, attorneys, claimants. Monitored claims for excessive medical treatment and authorization of care, coordinating file for medical exams (IME’s) and referring files for litigation.
United Health Care 1/96 to 2/99
E. Broad St
Columbus, Ohio 43225
Provider Adds./Clerk (1/96 to 10/96)
Reviewer (10/96 to 10/97)
Adjuster (10/97 to 2/99)
614-***-****, Kathy Gullett
Provider adds./Clerk: Responsible for basic clerical duties such as filing, copies and mail. Also generated the weekly reports for the department and ordered supplies. Non-participating doctor additions to the system involved calling to verify information and researching backgrounds. Data entry and enrollment was also learned during this time.
Reviewer/ Examiner: Continued doing the weekly reports for the department while training a new employee for clerk. Gathered data for the team, reviewed/paid claims, data entered and provided help to other areas as needed. Volunteered to be on companies “quality team” and the AI (artificial intelligence/automatic pay) team. Maintained review quality and turn around time while filling in for the department’s clerk/provider add. person for three months. Cross-trained and learned how to coordinate benefits (COB).
Adjuster: Responsibilities include maintaining COB turn around time and adjusting incorrect claims for the all divisions in the department. Close contact with customer service and technical analysts to resolve system problems and training issues is required. Continue to data enter and support other departments as needed.
La Petite Academy 8/94 to 3/95
1325 E Walnut Street 6/95 to 11/95
Westerville, Ohio 43081
Infant/Toddler Teacher
614-***-****, Colleen Murray-Earliwine
Responsible for 1 to 12 children. Closed and opened the building as needed. Served meals and provided individual care and education. Also turned in a weekly curriculum and daily paperwork for approval. First aid, CPR and infant care classes taken to enhance ability to care for younger children.
Taco Bell # 3319 6/89 to 8/92
2820 S Hamilton Road 3/93 to 10/93
Columbus, Ohio 43232
Shift Manager
614-***-****, Ray Mayhew, Bruce Neikirk
Supervise a crew of 2 to 10. Responsible for finances, paperwork, food orders, and customer relations. Completed scheduling and reviewed applications/hiring/firing as needed. Also closed/opened store (computer included) and did some outside sales work.
Kohl’s Department Store 10/92 to 1/93
2800 S Hamilton Road
Columbus, Ohio 43232
Cashier
614-***-****, Dave Kemp
Responsible for closing register and counting till at the end of a shift. Handled customers and did returns. (Seasonal).
Callander Cleaners 1/93 to 3/93
2850 E Main Street 4/94 to 7/94
Columbus, Ohio 43209
Front Counter Clerk
614-***-****, Ron Callander
Closed store, handled customers and all cash transactions. Bagged, tagged and controlled incoming and outgoing orders.
Education/Designations
Franklin University 2006
Previously enrolled in the accelerated, integrated MBA program with a 4.0 GPA. Focus includes a minor in global business. 6 classes remain.
Columbus State Community College 1991 to 2000
Attended CSCC and received an Associates of Arts degree. Graduated with a 3.5 grade point average in July of 2000.
Independence High School 1988 to 1991
Member of the National Honor Society and D.E.C.A. Received first place in the D.E.C.A. district championship for food service management. College prepatory and advanced placement classes. Graduated 25th in a class of 280. Grade point average 3.0.
Kentucky Adjuster’s License
Renewed and CEU’s completed 3/2019
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