Customer Service Medical

Lori R. Masterson

*** ****** *** *******, ** ****0 Phone: 860-***-**** *************@*****.***

Medical Claim Examiner

Highly personable detail oriented service professional with extensive experience in medical insurance processing, auditing, rating and underwriting. Insurance Medical Claim Examiner expert in evaluating complex claims, risk analysis, pricing, client management and medical terminology including ICD9/CPT4 coding. A high producer and strong team player focused on quality and problem resolution using effective communication skills.

Areas of Expertise

Superior Customer Focus ● Self Motivated ● Detail Oriented

Analytical Thinking ● PC Skills ● ICD9/CPT4

Plan Interpretation/SPDs ● Organizational Skills ● Independent/Team worker

Key Accomplishments

Lead Coordinator for medical management with team ensuring quality in operations

Contributed to growth of $32 million book of business through expert risk analysis

Lead team member for “Quality Rounds” establishing key role technical coach

Excellent quality with excellent production exceeding performance goals

Secured company achievement awards for delivery of exceptional customer service

Professional Experience

End-Game Strategy – Berlin CT 4/2014- Current

Senior Claim Overpayment Specialist

Responsible for validating overpayments of health care insurance claims using client specific reimbursement policy, CPT coding guidelines and CMS criteria. Researched claim history utilizing client’s claim payment systems while maintaining accurate documentation of all activity and interaction with clients.

Interpreted and applied policy and plan concepts

Identified overpayments

Handled all appeals from the client

Sun Life Financial – Windsor CT 11/2009-4/2014

Senior Stop Loss Analyst

Responsible for the professional management of a complex area of Stop Loss claims based upon extensive knowledge, expertise and experience. Reviews claims and makes final recommendation for admittance, discontinuance or denial. Approves payment of claims and Company liability within established limits. Responsible for training of staff, appeals and denials.

Reviews claim payments within established limits and/or reviews recommendations made by staff to determine proper disposition of claims and directs claim staff to ensure appropriateness of investigation

assists in managing claims activities to ensure that payouts are adjudicated in a timely, accurate and efficient manner

Provides technical expertise to senior management, underwriters, field sales and others regarding adjudication of claims, interpretation of contracts, regulation, and procedures

Lead team support for training and auditing trainees

Chubb & Son a division of Federal Insurance Co. - Simsbury, CT 8/2006-8/2009

Employer Stop Loss Underwriter

Provided quality Underwriting support to Manager, Producers, TPA's, Sales Representative, Staff and maintained accuracy on a daily basis, contributing to over $32 million growth. Selected new risks based on established company criteria. Utilized internal and external resources to research and analyze risk.

Assessed rate adequacy relative to exposure establishing profitable policy premium

Ensured compliance with underwriting directives for:

Properly maintained Stop Loss System on every policy quoted, including but not limited to:

Arbor Benefit Group – Farmington, CT 10/2003-8/2006

Claims Manager of Medical Underwriting

Reported to President of Medical Underwriting. Managed Stop Loss Claim Payments both individual as well as aggregate claim files to ensure proper payment of claims.

Reviewed claim reports, pre-cert reports, trigger diagnosis reports, to identify potential large claimants and set appropriate risk on pre-sale, renewal and ongoing business

Audited claimant files for accuracy in claim payment accordance with Plan Document

Assisted in estimating the corporate reserves, financial forecasts and designing provider reimbursement and incentive methodologies

Monitored and reviewed data from internal departments, reviewing it for content and accuracy, identifying and resolving associated problems

Cigna Health Care – Bloomfield, CT 11/1990-10/2003

Stop Loss Claim Auditor - Quality Review Technical Coach - Benefit Analysis

Responsible for ensuring assigned book of business, meeting established service metrics for timely settlement of Stop Loss Claims and medical claim payments.

Represented the Stop Loss Unit in expert team meetings and ensured Stop Loss accounts were set up accurately

Resolved all Stop Loss Financial and customer service issues for assigned book of business

Conducted claim review for Random, $5,000+ and defect tracking

Compiled results daily/weekly/monthly for individual and office roll up providing timely delivery of results to management team

Supported new hire training process conducting reviews and participating in training classes

Processed medical claims with the ability to analyze each claim according to plan benefits

Fraud Investigations monitored providers flagged for fraud

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