WANDA PEARSON

** **** *******, ***** ******, NJ *7079

973-***-****

ad2b8y@r.postjobfree.com

SUMMARY:

Experienced Quality Assurance Specialist skilled in operations optimization, relationship management, cross-functional leadership and collaboration, data analysis, loss analysis, forecasting, risk management, safety assessment, policy and procedure development, compliance management, customer support, and medical coding and terminology. Proficient in Microsoft Office with keen interpersonal, communication and organizational skills, as well as case management, decision-making, and extensive technical expertise.

WORK EXPERIENCE:

Quality Assurance Specialist 2018 to 2020

Examworks, Roseland, NJ

Administered in-depth evaluation of reports and accompanying medical records, followed up with reviewer with additional questions as needed, and certified report completion

Assessed physician specialty assignment applications to support analysis of the IME case

Identified and reported inaccuracies based on medical documentation and state guidelines

Certified that referrer reports were received by QA within specified timelines and followed up with IME/Peer Review provider

Drove QA team improvement by providing resources and balancing file requirements within client specifications and in compliance with company procedures and guidelines

Assisted and supported training and coaching of new QA personnel

Medical Only Claims Adjuster 2017 to 2018

Crawford & Company (Broad Spire), Inc., Berkeley Heights, NJ

Investigated claims by interviewing employees, employers, witnesses and physicians; adjusted claims for TPA clients when appropriate

Set reserves and determined compensability and total value of claims

Monitored medical treatment in conjunction with medical management personnel, approved medical bills for payment, and dispensed prompt authorization of medical services

Coordinated light duty availability with medical providers and employers

Conducted evaluation of assigned impairment ratings for accuracy and efficiently transferred claims or initiated IIB Benefits and EDI filings

Utilized ODG Guidelines and Workers’ Computation software to maintain adequate reserves for life of claim

Identified subrogation potential, documented recovery screen, and pursued recovery

Maintained claim closure ratio of at least 97%

Claims Adjuster 2015 to 2017

Crawford & Company (Broad Spire), Inc., Berkeley Heights, NJ

Determined settlement decisions in a prompt and equitable manner, and provided company drafts in payments for claims within authority limits

Charted the development of subrogation and third-party recovery potential and adhered to reclaim procedures

Senior Life Underwriter 2004-2013

Prudential Financial Corporation, Livingston, NJ

Assessed risk factors for Group Life, Individual, Short Term and Long-Term Disability coverage

Administered underwriting of $5K to $1M healthcare policies, and ensured client needs were met

Performed evaluation and analysis of APS-enrollment materials, medical evidence, and detailed medical information to determine rates based on state-specific guidelines

Communicated decisions to customers through written correspondence

Coordinated with Financial Underwriting in the development of rates, new business pricing, and the health plan renewal process

EDUCATION:

Bachelor of Arts in Business Administration (in process), Bryant & Stratton College, Buffalo, NY

Associate of Science (A.S.) in Health & Human Sciences, Bryant & Stratton College, Buffalo, NY