Analyst Customer Service
Resume:
Melissa Mulligan
*************@*****.***
Areas of Strength
Benefits, HR Policies, Short term disability, Workman’s Compensation, Retire eligibility, Claims, CPT, HCPCS, ICD9, reimbursement policies and payment principles, HIPPA, COBRA, managed care, Medicaid, MD Reed Guidelines, FSA,HRA, HR policies, FMLA, Disability, HCFSA,DCRA, 401K, management of resources, problem solving, business detailed, MS Word, Excel & Power Point, MS One note, Sales Force, FACETS, NICE,SAP, DPA, Intellis, SIR, CCT,UDS,UIS
Professional Experience
MetLife- Tampa, FL
Short Term Disability Claim Specialist 7/2017 – Present
Evaluate individual short term disability claims and exercise independent judgement, discretion and critical analysis to reach reasonable claims determinations that are is accordance with contract provisions and time service standards.
Manage assigned caseload within time service guidelines.
Provide timely, balanced and accurate claims reviews, and deliver decisions to claimants in a time sensitive and fast-paced environment.
Compiles file documentation and correspondence requiring extensive policy detail.
Communicate decisions to claimants and employers in verbal and written form.
Identifies information and resources needed to adjudicate claim.
Conduct lengthy detailed information-gathering phone calls with claimants, medical professionals and HR staff to obtain medical condition details, financial details, occupational details and other information.
Refer to external and internal resources to ensure a well-reasoned decision.
Clarify and reconciles inconsistencies.
Coca-Cola Company - Brandon, FL
HR Advisor II- Benefits - 2/2015 –6/2017
.Provide benefit support to Coca-Cola employees (current and prior), retirees and eligible dependents
.Assist with new hire elections throughout an employee’s career and beyond retirement for both U.S. and Canada
.Educate associates on inquires related to leave of absence, education reimbursement, vacation time and company provided benefits
.Work with multiple external benefit vendors as changes occurs and aligning resources to best serve customers
.Utilize multiple case management systems including Microsoft and Excel to manage calls and case work
.Assist retirees and termed employees with pension calculations
.Provide detailed description of pension annuity and lump sums withdraws or rollovers and the applicable taxes
WellPoint, Inc.- Tampa, FL
Grievance/Appeals Analyst I (Government Branch Division)- 9/2012-10/2014
Medical Claim Review Analyst III- Medicaid and Long Term Care (LTC) - 10/2/11 – 8/2012
. Provide expertise claims support by reviewing, researching, investigating,
processing and adjusting claims.
. Work with less structured, more complex claim issues
. Perform necessary claim adjustments as required once resolution is determined.
. Handle special claims/research projects as determined within given time frames
. Handle first level appeals within company required time frames
. Communicate with management identifying trends resulting in companywide impact
. Manage various tasks effectively and within a collaborative team oriented environment using sound
judgment in decision-making
. Process Medicare claims that route out of automatic adjudication/ Facets platform.
. Exceed department productivity standards, 10% above department average
. Maintain quality standards and turnaround time
. Detail-oriented with strong organizational skills, able to work well in a changing environment and perform
multiple tasks effectively and concurrently
Aetna - Tampa, FL
Clinical Claim Review Analyst / International Accounts- 10/2005 – 7/2011
Service Consultant/ National Accounts – 6/1999- 9/2005
. Review pre-specified domestic and international medical claims for appropriateness based on applicable policy limitations and provisions.
. Gather documentation needed to review, analyze and accurately settle medical claims
. Review billing patterns for possible fraudulent and abusive claims
. Utilize internal and external resources such as clinical nurses, regional physician assistants and medical director to gather data to ensure a well-reasoned decision
. Implement internal workflows
. Interpret institutional, ancillary and professional contracts and fee schedules
. Exceed department quality standards, maintaining backlogs and aged reports
. Perform data entry and make claim payment decisions while handling the caller
. Anticipate customers’ needs and act on them.
. Takes ownership and accountability for own actions and in support of customers’ requests
. Enhances customer satisfaction and retention
. Increase member satisfaction, retention, and growth by effectively delivering competitive services to members and providers through a fully-integrated organization
. Mentor trainees in classroom setting on system navigation, and customer service issues
. Take responsibility for supervisor calls and follow through with customer
Education
Hillsborough Community College - Associates in Business Administration
Community Involvement
General Federation of Women’s Clubs
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