Objective: I am an experienced disability claims analyst, mentor, coach and trainer seeking to integrate my 21 years of experience into a rewarding career with growth opportunities.
Knowledge, Skills & Abilities:
Teamwork, leadership, prioritizing, analytical and organizational skills.
Ability to work in a fast-paced production environment while maintaining high quality.
Ability to conduct interviews and gather information, analyze data and make accurate decisions in a production-oriented setting.
Able to follow detailed protocol with minimal supervision and provide requested status as agency priorities change.
Ability to interpret policies, rules and procedures independently
Effective time management skills.
Clear and concise interpersonal, verbal and written communication skills with professional/medical personnel virtually and in house that establish effective working relationships.
Knowledge of the functional limitations of physiological and psychological impairments.
Knowledge of medical terminology, medical abbreviations, pharmacology, disease processes and medical concepts applicable to tests and procedures used in diagnosis and treatment.
Knowledge of MS-Office programs
Knowledge of the principles and techniques of supervision.
Ability to review and understand medical and other reports and extract pertinent facts.
The University Of North Carolina at Wilmington, Wilmington, North Carolina
Bachelor of Science Degree in Business Management 1998
Assistant Life & Disability Claim Analyst, Principal February 2020 to present
Process short term disability claims and calculate pre disability earnings on a contractual basis and investigate preexisting conditions.
Prepare rationale for medical review, ICD- 9/10 coding
Obtain, analyze and investigate medical, financial and contractual information to make effective and timely claim decisions.
Communicate with customers, medical professionals and employers regarding medical conditions, restrictions & limitations, job duties, group short term disability policy provisions, claim decisions, status, and all other aspects of the claim process to ensure they fully understand the company's position.
Monitor and follow up on outstanding items to ensure compliance with regulations, service timing, and quality guidelines.
NC Disability Determination Services, Raleigh, NC 02/01/1999 to 02/17/2020
Manager I, Disability Determination Services (Training Supervisor I) February 2016 to February 2020
Train, coach and mentor new analysts including Medical consultants, and Psychiatric/Psychological consultants.
Compose materials, lesson plans, course objectives, instructional strategies and examinations.
Develop and deliver training to existing staff as determined by quality assurance trends and changes in federal and state laws and regulations and other factors.
Oversee the development, implementation and delivery of the Administrative and Medical training program for trainees, new Medical and Psychological/Psychiatric consultants for a 4-month training period.
Serve as the electronic claim’s analysis tool coordinator for the agency.
Create challenging and interactive exercises to meet all learning styles.
Administer entrance testing and coordinate interviews with teams of interviewers.
Supervise trainees, identify barriers to learning or changes to develop proactive intervention and develop individualized goals.
Monitor work performances and hold monthly conferences to review performance goals and other necessary documentation in compliance with training policies.
Meet with management to discuss placement of trainees within a work unit.
Served as Quality Assurance Analyst reviewing accuracy of decisions for the agency
Mentored struggling specialists on case processing skills development.
Participate in team meetings and in-service training to enhance job skills and personnel
Growth and development.
Continued processing of Medicaid and Federal disability claims to assist in meeting agency goals.
Disability Determination Specialist III (Case Consultant) August 2011 to February 2016
Provide mentoring and training to specialists and contract workers one on one or in a Medicaid unit setting on selected medical and administrative topics.
Supervise lower-level disability specialists; interview new applicants.
Measure and evaluate performance through case reviews for accuracy and effectiveness of policies, procedures and actions taken.
Conducts in-depth review of cases to assess both the appropriateness and timeliness of the determination process to ensure that programs and office policies/procedures are adequate and are being followed; completes review forms regarding findings and recommends alternate actions when indicated.
Informs supervisor of case processing problems which impact the individual and agency accuracy rates and processing times.
Provide guidance and direction on medical and vocational issues with regard to the development, evaluation and adjudication of claims.
Confer with agency medical and psychiatric consultants as needed to help specialists resolve complex medical issues.
Prioritize multiple tasks and achieve case development deadlines with a sense of urgency when necessary.
Evaluate identified high risk workloads and provide recommendations and feedback.
Assist the unit with working on claims when specialists are out of the office or struggling.
Perform duties as a Disability Determination Specialist I as needed and process Medicaid continuing disability review claims.
Disability Determination Specialist II (June 2007 to August 2011)
Adjudicate social insurance program reconsiderations, continuing disability review claims, Hyatt court cases and medical assistance claims to document lifelong impairments by reviewing regulatory documents, evaluating data on forms while complying with HIPPA regulations, state/federal government regulations and confidentiality agreements with third parties.
Consistently manage a case load, review and re-analyze medical evidence and prior analysis using more details to assess severity of physical and mental diagnoses to assure all protocols and procedures were performed and documented correctly on the initial development of the claim.
Resolve inconsistencies in data, by requesting additional information from client/medical doctors or appropriate staff, follow up on outstanding medial document requests, in addition to scheduling medical exams and ancillary testing when appropriate.
Prepare rationale for medical review by MC/PC virtually and/or in house,ICD- 9/10 coding
Disability Determination Specialist I (February 1999 to June 2007)
Adjudicate claims using Federal Social Security laws and regulations for the Medical Assistance program in a Medicaid unit which required medical terminology and knowledge of pharmacology and disease processes.
Review of regulatory documents and evaluate data on forms, complying with HIPPA regulations, and confidentiality agreements with third parties.
Manage a caseload by implementing an independent work plan for the quarter.
Make accurate and timely decisions in a production-oriented setting as regulated by state mandated deadlines.
Correspond with clients to elicit information and document the outcome. Request vital records from physician offices and/or hospitals pertaining to the claim.
Extract the necessary information from medical charts, create a logical and longitudinal written analysis to sufficiently evaluate the clients’ diagnosis, conduct follow ups by contacting medical source or the client. Document my findings daily in the system. Request and set up medical exams for clients with insufficient medical records. ICD-9/10 coding to adequately review the medical diagnosis.