Vicki Stephani

*** *. **** ******, ***** Creek, WI 54106 • 920-***-**** • adlmrm@r.postjobfree.com

BACKGROUND SUMMARY

Experienced Customer Service / Administrative Professional / Policy Compliance/ Subrogation / Teaching with background in insurance claims, federal and state regulatory compliance, subrogation, and non-profit social services programs. Respected for sensitivity and confidentiality when dealing with target audiences. Strong interpersonal communication skills with an emphasis on customer service. Flexible with ability to multi-task time-sensitive projects in a fast-paced environment while maintaining accuracy and organization. Strong troubleshooting and research skills. High comfort level using multi-screen/multi-software program to accomplish responsibilities. Demonstrated strong work ethic and commitment to position.

DEMONSTRATED STRENGTHS

• Customer Service • Claims Processing • Benefit Interpretation

• Database Management • Research / Problem Solving • Quality Control

• Program Implementation • Case File Management • Regulatory Compliance

• Subrogation • Collections • Teaching

EMPLOYMENT HISTORY

NETWORK HEALTH – Menasha WI January 2, 2018 to January 7, 2021

Answer Network Health members, providers, and agents phone call and worked to resolve their issue in one call.

Work on all lines of business to help Network Health members to understand their insurance plan; gave benefits; answered questions on claims, solved enrollment issues, solved pharmacy issues, and worked with the marketplace, agents, and providers.

Provided call back to member from voice mail and worked incoming emails to provide excellent member service.

Worked with enrollment, finance, utilization review, pharmacy, and other departments to help improve our service to resolve members’ issues.

Protected HIPAA of our members.

Helped fellow co-workers to solve questions from members.

Worked as a mentor to new trainees to acclimate to the call center, how to resolve problems, and encourage them that they will become comfortable in their position.

Trained people on the email system and how the emails are processed.

Have attended meetings on rewriting contracts on behalf of the supervisor.

Assisted with updating and validating DLP’s and with HIX open enrollment guides.

Looked over new HIX material for managers to verify nothing is missing. Gave feedback on continuing problems with HIX procedures.

My coworkers trust my knowledge on all lines of business, computer, and marketplace issues for members.

Answer co-worker’s questions from a help line. Teach how programs work and how to answer medical insurance plans. Mentor new employees on doing the customer service position. How to handle complicated and angry callers.

OPTUM – Howard, WI April 13, 2015 to August 17, 2016

Recovery & Resolution Analyst

Set up new case, by obtaining accident details, injuries sustained, attorney information, and insurance claim numbers and contacts.

Performed verbal and written communication to member, insurance companies, attorneys, District Attorneys, and other entities.

Call attorney’s and insurance companies to collect payment on medical liens.

Follows and adheres to all federal and state compliance guidelines.

Analyze and identify trends and provides report to appropriate people.

Contributes suggestion to help improve quality and efficiency in procedure.

Use outside resources to obtain coordination of benefits data.

MULTIPLAN - De Pere, WI November 2010 to April 2013

Claims Operations Specialist

•Hired for new project focused on providing suggestions to improve process and identify savings.

•Determined why computer did not automatically process claims with pricing and sent resolution to internal department to improve computer accuracy.

•Performed functions supporting corporate objectives and needs of Claim Operations department, specifically related to Whitespace projects.

•Researched claims and claims data in MultiPlan’s or designated client’s claim systems and/or performed provider matching.

•Located and identified requisite claim information necessary for processing.

•Alerted leadership team when client’s claim systems were unavailable. Provided follow-up to ensure all pended claims were resolved within specified timeframes.

•Met and maintained daily production goals, expectations, and claim processing levels.

NETWORK HEALTH - Appleton, WI December 2009 to February 2010

Claims Analyst (Temporary Position)

Examined and processed paper claims and/or electronic claims in accordance with policy provisions.

Determined whether to return, pend, deny or pay claims and steps for claims adjudication.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA - Appleton, WI October 1986 to June 2009

Claims Processor (1991 to 2009)

Reviewed and approved medical claims for payment or denial. Analyzed eligibility for coverage; compared claims with contract guidelines for approval or denial.

Investigate and apply state legislation laws to improperly processed claims

Investigated questionable claims and determined proper action, based on findings.

Worked with Provider Networks to resolve problem issues with participating and non-participating contracts.

Performed adjustments on claims due to appeals, incorrect information, and previously denied claims.

Applied federal, state, and contract language to claims and appeals.

Reviewed accidental claims eligible as auto accidents or worker’s compensation claims.

Reviewed claims for subrogation and collections of overpaid claims.

Complied with applicable federal, state, and HIPAA laws.

Provided information and resolved differences with policyholders, agents, brokers, physicians, hospitals, attorneys, consultants, and other employees.

Investigated appeals made on claims and answered using letters and/or phone calls.

Provided excellent customer service to claimant’s regarding their claim, along with contact with physician’s offices, hospitals, and other insurance companies.

Problem-solved potential issues with new computer systems for the claims processing operating system.

Account Reviewer (1986 to 1991)

Reviewed enrollment forms for eligibility for coverage under contractual guidelines.

Applied waiting periods, added dependents, referred Evidence of Insurability forms to Underwriting for further investigations.

Made changes in terminating coverage and added benefits including life, AD&D, STD, LTD, major medical, and dental benefits.

Prepared billing statements, matched premiums to billing, reviewed l delinquent accounts and prepared lapse of policies. Provided customer service to plan holders, regional offices, agents, and brokers.

RELATED / VOLUNTEER ACTIVITIES

Salvation Army - Appleton, WI 2007 to 2009

•Demonstrated leadership skills and viewed as resource to volunteers and others needing guidance/answers to questions.

Created forms and assisted in development of Access database to store client information.

Developed program for used by Holiday Cheer program to create a data base used to identify holiday gifting needs.

Served as local unit’s secretary and attended meetings/took minutes and contributed to the running/function of the unit.

Developed disaster response including constructing goals, guidelines, and outlines of task to create disaster plan including government officials

Organized volunteer disaster workers and helped with two WI floods in 2007.

Choir Director & Organist / Youth Teacher / Concert Organizer 1991 to 2006

EDUCATION / TRAINING

B.S. - Health Administration/Health Management; University of Phoenix – Phoenix, AZ

A.A. - Business Administration in Health Care; University of Phoenix – Phoenix, AZ

Disaster training courses/workshops - Salvation Army

TECHNICAL SKILLS

Microsoft Word • Excel • Access • PowerPoint • Publisher • Lotus Notes • Siebel • iProcess • Microsoft Windows

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