Sharon Miller

**** ** *** ***** **

Port St Lucie, FL 34983 US

Phone: 561-***-****

acy3ro@r.postjobfree.com

Profile: Administrative Specialist

Seeking employment close to home where I can continue to be of service and impact the livelihood of people in need of a betterment of life with a team of productive individuals in a structured work environment.

Career Enhancements:

Time Management Communicator

Multi-tasker Knowledge of Best Practice and HIPAA Compliant

EMPLOYMENT HISTORY

Humana American Eldercare LTC Insurance Program 7/1/13 to 12/27/16

This was the most enjoyable and rewarding experience in all my years of working

Job title: ADA Rep “Authorization Data Analysis”

Responsibility: Review Case Manager “CM” aka Nurse request within a two business day timeframe to determine if the submission for maintenance is appropriate for member’s current health care and living status; whether member is a home member, ALF member, SNF Custodial or Hospice Member (Medicaid ONLY or Dually Eligible)

Based on member findings determine whether approval or cancellation of a request is processed

Communicate via telephone, e-mail or IM with the “CM” Case Mgr., along with written recommendation(s) on the submitted request. If the request is 3 days out I make contact with CM. Supervisor aka “CMS” Case Mgr. Supv., and Regional Director aka “RD” to bring clarity to the request to help in determining the outcome for final processing. I resolved Provider billing issues and processed E-Billing CMS-1500 form / NOCAs, NOAL, PASSR

Trained – Temp workers

Daily process requirement: 85; I averaged 100 to 120 requests per day Monday thru Friday, approximately 550 request weekly and when available - OT

Gallagher Bassett: (Miramar/Sunrise location) 7/1/11 to 6/23/13

Free State Staffing Agency: Gallagher Bassett Services (TPA) 12/2010-6/30/11

Responsibilities: (A range desk) manage B.O.B range 150 to 250 caseload of WC Claims from inception to closure

Claim management includes taking recorded statements, 3 point contacts, witnesses “if necessary” to determine compensability or denial of a WCC in a timely manner

Monitor all medical activity, include NCM when needed, and request surveillance if file dictates

Aggressively pursue all avenues of claim resolution to effectively manage payouts, i.e. return injured worker to pre-injury work status and discontinuance of benefits

Adequately set or adjust reserves according to file dictation at any given time

Set repetitive pay to ensure the timely bi-weekly payments of claimants disability benefits

Diary / POA for future claims handling according to file dictation

Update Clients as per Service Instructions “SI”

Maintain DSR’s for claims that met reportable reserve threshold “Client determination”

E-billing and E-invoice pay CMS-1500 / ICD-9 coding

Multiple Clients / Multi- State claims handling M/O

NCCI Holdings Inc., Claims Auditor 2010-2007

Responsibilities: were to perform on-site workers’ compensation claim audits to determine if Servicing Carriers of the National Workers’ Compensation Reinsurance Pool were in compliance with NCCI’s guidelines, performance standards, state regulations, applicable bid enhancements and Best Business Practices.

In house preparation for on-site audits included interfacing with carrier contacts to ensure required

materials were available prior to arrival

Planned and conducted entrance and exit meetings during on-site audits

Developed recommendations based on the findings during an audit

Oral presentations addressing CEO’s, VP’s and Branch Management of Insurance Companies

Average 30 to 35 claims weekly, surpassing goal of 4 to 5 daily (35% above quota).

Provided evidence leading to the recovery of thousands of dollars in insurance overpayments

NIAS National Insurance Advisory Systems aka Acu-Comp Sr., Claims Auditor 2007-2005

Responsibilities: were to audit current reserves against the exposure of loss time WC claims and make recommendations to the future handling of the claim with anticipation of reducing the reserves and ultimately bring forth closure or settlement negotiations.

Managed 1300 to 1400 Worker Compensation (WC) Claims Book of Business annually

Knowledgeable of various State Regulations/Laws and Best Business Practices

Developed recommendations based on the findings during an audit

Formal written reports distributed to Insurance Agents & Carriers

Personnel One Job Placement Agency NASD – Legal Secretary 2005-2004

Responsibilities were to prepare and send out correspondence i.e., motions, briefs, subpoenas, pleadings, etc., calendar maintenance for hearings and mediation with Arbitrators and Mediators.

Prepared and processed Arbitrator / Mediator packets.

Communicated with opposing counsel offices to coordinate hearing schedules

Computer & Program Proficiency / Knowledge

Humana Systems: CGX, Billing: CAS, HOD Mod4 / ACHA

AEC “American Eldercare” Network site: Silverling, Que, FMMIS “DCF Site”

Risx-Facs-claims program to include: workbook, client profile, SI,

Classic – claims program to include: IW’s information, TE worksheet, POD, Reserve

Microsoft Office Suite / Microsoft Word, Office Professional 200, Doubletime, Propel

Claims Automated Audit “CAA”

Office Professional Database “OPD”

Network Platforms: AS400, Windows NT / XP, Novell

WordPerfect 9.0, WordPro, Wordstar, Quatrro Pro, Microsoft Access, Excel and Microsoft Works

EDUCATION

AA Degree in Paralegal – West Palm Beach, FL

Word Processing – Tampa, FL

Prior Certified Accredited Claims Adjuster

REFERENCES UPON REQUEST

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