Marietta R. Grier

**** ** **** ****** **** Park, FL 33023 305-***-**** actm88@r.postjobfree.com Objective:

Acquiring a position with a company for a number of reasons. Those being, the opportunity to learn and grow within a professional medical managed care or benefit administration atmosphere, participate in public and employee relations, pinpoint and utilize knowledge and skills in which I excel to promote my career..

Dedicated insurance professional Insurance Claims with more Profile than – Disability 5 years of Line experience Specialty investigating and processing disability and absent leave insurance claims. I excelled in applying strategy to ensure accurate and prompt payment, effectively managed multitudes of priority projects and took pride in providing exemplary customer service.

Claims Handling and Investigations

Risk Assessment and Mitigation

Policy Interpretation

Compliance, Grievance, and Appeals

Claims Reports and Documentation

Confidential Records Management

ERISA/ADA/HIPPA/Federal and state

law regulations

Cleveland Clinic Florida- Weston, Florida January 2014 to present Health Unit Coordinator

Perform the gathering and organization of surgical patient data, preparation of charts, and collections of statistical data. Complete physician order process and order entry. Answers call light and follow up with appropriate staff. Participate in peer evaluations. Generate reports for unit admission, discharges, and transfers. Monitors ongoing outputs, process and satisfaction level within area of responsibility to identify and prioritize areas for improvement. Use information for feedback to recommend system modifications. Assist in implementation of surveys to monitor if unit is meeting needs of customer. Complete occurrence reports. Participate in hospital emergency preparedness drill. Attend monthly departmental managers meeting, is responsible for all communication at the meeting. Communicate philosophy of management decisions to departmental staff. Assume leadership role in departmental activities that promote interaction with community organizations. Act as receptionist for Telemetry and Medical/Surgical units.

Aetna Insurance Company – Plantation, Florida June 2001 – July 2011 Sr. Disability Benefit Claims Manager, 2/06 to 7/11 Conducted prompt and thorough investigations, evaluated and interpret facts, to determine extent of functional impairment for disability insurance claims. Consulted with claimants, policyholders, attorneys, and physicians’ directly either verbally or written communication to facilitate proper utilization of benefits and ensure equitable resolution. Maintained vendor contact to investigate discrepancies and provide information in non- routine situations to guarantee compliance and accuracy of benefit policy. Monitored activity to identify possible fraud or third party liability. Utilized established review procedures and resources to facilitated effective transition of short term to long term and/or return to work status. Ensured benefits were within expected levels of service in support of weekly payroll process. Identified and responded to crisis calls. Implemented training updates at weekly staff meetings incorporating communication material for review. Provided optimum customer service to policyholders.

Promoted to senior level within one year of case management

Achieved the highest number of modified duty return to work accommodations in 2010

Designated to assist with outdated file closures; resolve claims-processing issues; train and mentor new employees, and monitor random quality audits.

Maintained a superior quality rating of 99.6% in file handling and claims resolution from 2007 to 2010.

Utilization Management Triage Coordinator, 4/03 to 2/06 Collected, analyzed and maintained medical data for utilization review of workers’ compensation medical service requests. Obtained verification of all referrals received, and responded to inquiries regarding referrals that did not meet criteria. Distributed nurse reviewer case workloads for either concurrent or retro review. Scheduled and participated in peer reviews for supporting evidence based data and appeals. Accompanied nurse case managers by means of determining completeness and validity of claims and effectiveness of cost measures. Tracked utilization department data to twig trends for improvement process. Mentored Intake staff. Participated in medical necessity URAC, clinical and quality training updates. Developed a strong understanding of insurance policies and legal issues. Medical Bill Review II/Bill Appeals, 6/01 to 4/03

Accessed ICD 9 and CPT codes in conjunction with adjusters claim summary notes to determine medical bill causality. Authorized medical bill payments. Pended and redirected denials to claim adjuster. Accurately entered medical bill data into Igenix bill system. (HCFA 1500, UB92, RX, and NSF). Maintained, added, and updated claimant and provider data. Monitored and corrected inaccurate, outdated, and duplicate bills. Communicated with providers to obtain data for resolution of specific bill issues. Identified over and under payments. Researched and resolved medical bill appeals. Maintained turnaround time, and deadlines per client contracts. Participated in ongoing training to maintain compliance with process changes, HIPPA, and ARRA laws and regulations. KNOWLEDGE, SKILLS & ABILITIES

• Knowledge of organization policies, procedures, systems, and objectives.

• Knowledge of insurance billing and collecting, and budgets.

• Skill in planning, organizing, and supervising.

• Skill in exercising initiative, judgment, problem-solving, and decision-making.

• Skill in developing and maintaining effective relationships with medical and administrative staff.

• Ability to communicate effectively both in writing and verbally.

• Ability to counsel/discipline personnel as requested or as may become necessary.

• Ability to delegate authority, responsibility to other staff personnel as deemed necessary to perform their assigned duties.

• Ability to handle information in a confidential manner Broward Community College, Sheridan Technical Center: - Hollywood, FL Completed extensive training in customer service delivery, medical terminology; Medicare/Medicaid; ICD 9-10; HCPCS; statutory regulations; URAC, workers compensation basics, and claim administration. I’ve also obtained Medical Assistant, Patient Care Technician, Phlebotomy, BLS and EKG certifications. Currently pursuing Information Technology and Management AS degree.

Computer Skills: Microsoft Office applications, Citrix Xen applications, Market Prominence, E-saws, Epic, and Workability database programs, and Internet Explorer References: Professional References available upon request

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