Alice M. Johnson

Email: acwsza@r.postjobfree.com – Ph: 773-***-**** – Address: 5719 S Michigan Avenue • Chicago, IL • 60637

CAREER SUMMARY

Accomplished professional, with extensive experience in analyzing and investigating health and life insurance claims. Equipped with comprehensive years of experience in medical, vision, dental, life, waiver of premium, short and long term disability as well as stop loss claims. Well-versed in establishing solid relationships with professionals and individuals while maintaining high ethical and quality standards. Effectively manages multiple, high-priority projects; takes pride in providing exemplary customer service and possess outstanding problem-solving and leadership skills.

PROFESSIONAL EXPERIENCE

BCS Insurance – Oak Brook, IL

Claims Analyst, 2009 to December 1, 2014 (Retired)

$250K approval authority.

Expert in claim life cycle for: Medical, Life, Group Universal Life, Organ Transplant, Short & Long Term Disability, and Vision & Dental expenses.

Determines extent of company's liability; makes approval or denial decisions and negotiate settlements in accordance with policy provisions. Collaborates with insurance agents; interview claimants to correct errors, rectify omissions and investigate questionable issues.

Strategically identifies claimants’ eligibility for disability through analysis and evaluation of medical records and other related documents. Executes investigations on insurance claims related to bodily injury, liability, medical, and employee compensation.

Frequently communicates claim activity and processing with the injured party and the client.

Achievements

Recommended and redesigned claim processing procedures thereby improving efficiency by 20%.

Decreased claim processing error from 5% to less than 1% by developing training guidelines and manuals for new Claim Professionals which helped to ensure proper coding and claim data entry.

Achieved the highest number for claim processing (out of 12colleagues) in 2013. Surpassed goal by handing a high volume of claims monthly (23% above quota).

Selected by manager to resolve complex claims-processing issues; participate in quality-control audits; and monitor claim status updates.

Maintained a superior quality rating of 94% in file handling and claims resolution from 2009 to 2014, exceeding the 90% departmental goal.

Received Peak Performer Awards (2008, 2007) and Service Excellence Award (2007).

Provided optimum service to policyholders, negotiated fair settlements and identified fraudulent claims.

Claims Technical Analyst, 1986 to 2008

$150K approval authority.

Determined benefits due; made timely claims payments and adjustments. Used appropriate cost containment techniques including strategic partnerships to reduce overall cost of claims.

Entered claim payments, reserves and new claims in software program, inputting concise yet sufficient file documentation. Conferred with legal counsel on claims requiring litigation.

Contacted or interviewed claimants, doctors, medical specialists, or employers for additional information.

Delivered excellent service and ensured total satisfaction by preparing forms, addressing concerns regarding filing requirements and benefits provided to claimants.

Achievements

Level 2 approval authority for complex, severe exposure claims; used expert knowledge and high-service file handling.

Assisted with the design and implementation of updates to the claim system and the development of the claim tracking process.

Spearheaded the timely preparation and creation of production reports.

Organized and conducted staff meetings; selected topics on training and development, employee motivation and new insurance laws and regulations.

Claims Examiner, 1980 to 1985

$50K approval authority.

Negotiated settlement of claims up to designated authority level and made claim payments.

To ensure that claims were valid and that settlements were made according to company practices and procedures, verified and analyzed data used in settling claims.

Maintained claim files such as records of settled claims and an inventory of claims requiring detailed analysis.

Obtained knowledge of ICD-9, ICD-10 and CPT coding, stop loss and loss adjustment.

Employee Participation

Member of the Culture Team which encourages employee team building, social activities and motivation.

Member of Toastmaster.

Professional Development Classes

Insurance Fraud Coursework (2014)

Kaplan/ Ethics and Regulation (2013)

Kaplan/Delivering Quality Service (2013)

Insurance Institute/Worker’s Compensation (2012)

Introduction to Property & Casualty Insurance (2011)

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