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Medical Customer Service

Location:
Philadelphia, PA
Posted:
May 15, 2020

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Resume:

NIAMBI BURTON

Executive Profile

Driven Senior Medical Stop Loss Claims Auditor with 13 years of experience within all aspects of High Level Claims Management and as well as Administrative and Clerical expertise. Highly trained and experienced in Medical Stop Loss Insurance Claims, auditing, reimbursement, and negotiation skills with clients, and or vendors to maintain, and achieve quality assurance that will favorably affect the entire block of business.

Skill Highlights

Leadership/Communication Skills

HIPAA Compliance

Database Management

CPT and HCPCS Coding

Staff Development

Cost Management

Medical Coding

Quality Management

Knowledge of Medical Terminology

Administrative Skills

Professional Experience

Tokio Marine HCC (New Opportunity. I resigned because the daily commute was too long) Kennesaw, GA

Specific Stop Loss Auditor

October 2018 – May 2019

●Reduced stop loss ratios through fair, and prompt processing of claims.

●Analyzed first reports of loss, and underlying file material to determine if a claim was reimbursable.

●Notified reinsurers of all high dollar claimants once contracted thresholds had been met, as well potential future high dollar claimants.

●Requested and recommended Cost Containment from vendors for all potential high dollar claimants.

●Maintained requested deadlines and provided Customer Service by responding to daily claims inquiries and requests from multiple MGU’s.

●Maintained administrative, procedural processes to improve accuracy and efficiency.

●Completed month-end Specific reserves in database and reported final reserve reports.

●Contacted third party administrators, reinsurers, medical vendors, and legal representatives to negotiate final settlements for claims.

●Obtained all necessary information to complete proper evaluation of injury claims.

●Investigated claims, conducted field audits, determined losses, and reported findings.

●Investigated any potentially fraudulent claims with a focus on thoroughness, quality, and cost control.

●Calculated and verified Coordination of Benefits (COB).

●Knowledge of HIPAA Compliance Law.

Kentucky Health Administrators (Temporary position)

Lexington, KY

Claims Coordinator/Claims Specialist

February 2017 – May 2017

●Verified, logged, submitted all 50% reports, Monthly Aggregate, LCM reports, and Claims Reimbursement Requests.

●Maintained requested deadlines, and provided Customer Service by responding to daily claims inquiries and requests from multiple MGU’s.

●Maintained administrative, procedural processes to improve accuracy and efficiency.

●Verified bi-weekly check runs for reimbursable claims, and made sure that all requested and reimbursed amounts were accurate before checks were mailed out to the MGU’s

●Audited all claims before they were submitted.

Underwriting Management Experts (Resigned to take care of ill family member) Lansdale, PA

Senior Medical Claims Auditor/Claims Department Lead Manager

January 2015 - December 2016

●Reduced stop loss ratios through fair, and prompt processing of claims.

●Analyzed first reports of loss, and underlying file material to determine if a claim was reimbursable.

●Notified reinsurers of all high dollar claimants once contracted thresholds had been met, as well potential future high dollar claimants.

●Knowledge of HIPAA Compliance Law.

●Calculated and verified Coordination of Benefits (COB).

●Received, audited, and approved signed plan documents for in force cases.

Montgomery Management INC (Resigned for a New opportunity) North Wales, PA

Medical Stop Loss/Level Funded Claims Auditor March 2010 – January 2015

●Served as subject matter expert in Level Funded weekly, monthly, and end of policy year auditing, auditing of Medical Stop Loss Traditional, and Specific Claims.

●Reduced stop loss ratios through fair, and prompt processing of claims.

●Analyzed first reports of loss, and underlying file material to determine if a claim was reimbursable.

●Notified reinsurers of all high dollar claimants once contracted thresholds had been met, as well potential future high dollar claimants.

●Requested and recommended Cost Containment from vendors for all potential high dollar claimants.

●Completed month-end Specific and Aggregate reserves in database, and reported final reserve reports.

●Contacted third party administrators, reinsurers, medical vendors, and legal representatives to negotiate final settlements for claims.

●Obtained all necessary information to complete proper evaluation of injury claims.

●Investigated claims, conducted field audits, determined losses, and reported findings.

●Attended anti-fraud training classes.

●Investigated any potentially fraudulent claims with a focus on thoroughness, quality, and cost control.

●Created spreadsheets to improve claims management, and reporting accuracy.

●Mentored, and trained numerous new employees, as well as recently promoted employees of the claims staff.

●Calculated and verified Coordination of Benefits (COB).

●Received, audited, and approved signed plan documents for in force cases.

●Managed and conducted biweekly department meetings.

●Provided reporting for CEO and sales team on managing operations, and work flow.

●Knowledge of HIPAA Compliance Law.

●Completed proper email etiquette workshop.

●Completed Stop Loss 101 course.

Claims Coordinator

February 2009 – March 2010

●Verified and logged in deadlines for responding to daily inquiries.

●Maintained administrative, procedural processes to improve accuracy and efficiency.

●Handled weekly check runs for reimbursable claims, and mailed checks and EORs to Third Party Administrators.

●Received, audited, and approved Groups Signed Plan Documents.

Underwriting Coordinator Director

October 2005 – February 2009

●Directed and coordinated department functions for a team of five employees.

●Standardized department filing system to increase efficiency.

●Verified and logged in deadlines for responding to daily inquiries.

Education

Ashworth College Norcross, GA

Medical Billing and Coding

Community College of Philadelphia Philadelphia, PA

Nursing



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