Sales Insurance
Resume:
Christina Nelson
Atlanta, GA 30328
************@*****.***
[pic]
Objective:
Highly motivated, organized and creative problem solver; skilled at
analyzing business needs and utilizing a win-win style of negotiating to
resolve disputes. Seeks a position that highlights my twelve years of
professional experience and knowledge to achieve the required results.
Academic Credentials:
. Bachelor of Science, August 2000, Florida State University,
Tallahassee, FL
. BISYS Certification of Workers Compensation coverage, Completed INS21
course
. Certified Fraud Examiner certification in progress March 2014
__
Professional Summary:
. Five years of experience working for a rating organization allowed me
to gain expert knowledge of workers compensation manuals (Basic,
scopes, and Experience Rating Manual) in addition to knowledge of
NCCI, ISO, and various DOI's rules and guidelines.
. By auditing various types of businesses and working directly under
senior management, I can effectively communicate to audiences at all
levels.
. Able to present subjects clearly to both technical and non-technical
audiences with ideas that are concise and logical.
. As a compliance analyst, I was provided an opportunity to apply my
analytical, interpretative, problem solving and research skills
tactfully and effectively in difficult situations. As well as, educate
and interpret rules and regulations to internal/external customer's
needs to develop an appropriate solution.
. As an associate underwriter, I demonstrated a commitment to superior
service in Customer Relations by identifying customer's needs and took
the appropriate actions to meet those needs.
. Working in a virtual office allows me the ability to work
independently by using organizational, time, and desk management
skills. While being able to work independently I also promote positive
results within a team environment and was voted "MVP" by peers.
Employment History:
2012- Present Program Integrity Audit Specialist, Northstar Healthcare
Consulting. Alpharetta, GA
-Conducted onsite audits of Durable Medical Equipment (DME) on behalf of GA
Department of Community Health.
- Plan and direct auditing of patient files to evaluate the adequacy and
accuracy of documentation in support of services billed, including ICD-
9/HCPCS, medical necessity of services, reimbursement overpayments and
underpayments, and compliance, coding and billing standards.
-Ran claims data through proprietary queries to find patterns, anomalies,
errors, and potential fraudulent activity.
-Analyzed patient claims data reports to identify fraud and abuse.
-Provided written reports of notification outlining identified
discrepancies and reimbursement to the division.
-Conducted administrative reviews as part of the administrative review
committee and report findings to appropriate party.
-Ensured compliance with HIPAA rules and regulations
-Provide recommendations and updates approved for GA DCH policy and
procedures manual for durable Medical equipment.
-Mail monthly surveys to randomly identified members to validate receipt of
medications whose claims have been submitted by retail pharmacies through
Medicaid pharmacy network
2009- 2012 Premium Auditor, Overland Solutions, Inc,
Duluth, GA
-Performed DME Medicare supplier onsite inspections for Palmetto GBA,
National Clearing house, and Centers for Medicare & Medicaid Services
(CMS).
-Collected data to ensure DME supplier compliance.
-Photographed supplier operations and current inventory to ensure proper
billing of DME supplies.
-Reviewed DME beneficiary patient charts to ensure required records were
maintained.
-Conducted interviews with DME suppliers.
-Conducted Audits on selected workers compensation, General Liability, and
Garage policies
-Visited insured's locations to audit relevant records (payroll, A/R, A/P,
sales, & Vehicles) tour facilities and create description of operations,
job site, and procedures.
-Reviewed insured's business operations including examining, verifying and
recording pertinent data specific to the insured's business.
-Ensured the proper risk classification and exposure basis identification.
-Provided recommendation of appropriate classification when risk is
improperly classified.
-Conducted PEO audits ensure proper classifications associated with PEO
policies.
-Communicated results to carrier in a timely manner make classification
recommendations and notify of any underwriting alerts.
-Examined financial records such as payroll registers, quarterly
941's/SUTA's, General Ledgers, Sales ledgers
-Discussed issues and problems with the insured to ensure understanding of
the change in premium.
-Verified and review claims data.
-Managed assigned geographical territory.
2006-2009 Compliance Specialist, Builders Insurance Group,
Atlanta, GA
-Maintained credit incentive factor for quality data reporting while
company experienced system issues.
-Monitored and reported NCCI & ISO updates state regulatory, and statute
changes.
-Served as liaison and advisor for all internal departments in research and
training in compliance related matters.
-Reported and corrected policy, claim, and unit statistical data to NCCI
and various State Bureaus.
-Evaluated statutory requirements for new states in which the company may
conduct business.
-Assisted with Department of Insurance disputes.
-Provided "best practice" recommendations to support the business that meet
regulatory, ISO and NCCI guidelines.
-Provided advice and guidance to ensure appropriate operating procedures
and controls are in place
-Submitted rate and form filings electronically through SERFF
-Coordinated state rate filings, conducted monthly file audits on
underwriting and premium audit files, generated monthly rate filing
reports, assisted with special projects and legal research as needed by
General Counsel and Commercial Lines Departments.
-Facilitated compliance training for new hires and existing staff.
2001-2006 Experience Rating Analyst, NCCI, Boca
Raton, FL
-Produced Experience Rating Worksheet
-Processed ownership rulings
-Reviewed merger and sales agreements in order to determine ruling.
-Researched problems, report findings, and make recommendations.
-Assisted external and internal customers with questions and concerns
regarding experience modifications and Ownership rulings in a timely
manner.
-Processed Employee leasing request and ERM-6's (for affiliate and non-
affiliate data).
-Involved in monthly SWOT team strategy sessions.
-Team's " SME " (subject matter expert) in processing separate data request
- Responsible for probing and understanding customer concerns while
recognizing ongoing changes in hundreds of industries.
-Responded to questions and issues from producers, carriers, employers and
regulators.
-Provided experience modification, classification, and Assigned Risk policy
advice to customers.
-Performed underwriting assigned risk applications for completeness and
eligibility
-Followed up as necessary. Reviewed standard class codes applied, assisted
carriers in issuing policy and determined and collected premiums.
-Assisted customers on completing and updating Assigned Risk policy
Applications and navigation through on-line tools.
-Recorded and analyzed suspected insurance fraud reports daily and
forwarded findings to the National Insurance Crime Bureau
-Actively created and maintained customer contact information in CRM
program.
Technology skills: Proficient in Microsoft Office products (Word, Excel,
and Power Point) visual audit, Microsoft SQL, auditing programs, FTP, CRM
Programs, AS400, Scheduling applications, SPSS
References provided upon request
Contact this candidate