Customer Service Benefits Specialist

DEBORAH F. WALKER

***** ****** ****** ***** ************, IN 46229 412-***-**** **********@*****.*** PROFESSIONAL SUMMARY

With over 20 years experience in the healthcare industry, I have a reputation as a self-directed professional with superior problem solving, communication, and leadership skills. Serves as subject matter expert responsible for providing functional and technical guidance to staff. Monitors daily productivity reports to ensure adherence. Performs all job responsibilities of assigned team as needed to ensure departmental compliance to objectives. Capable of working in a fast-paced environment, managing multiple, diverse tasks simultaneously. Proficient in Microsoft Office. AREAS OF EXPERTISE

Third-Party Liability

Liability Resolution

Complaints & Grievances

HIPAA/Medical Terminology

Leadership and Development

Medical Investigations

PROFESSIONAL EXPERIENCE

WorldTrips Travel Insurance, Indianapolis, IN (11/2015 – present) Sr. Appeals Administrator

Core Expectations:

Prepare and facilitate member appeals, complaints, and grievances, to obtain the necessary information to complete the appeal process within the time period allowed by regulation.

Investigate and adjudicate complex claim requests and claims requiring special handling, such as reversals, adjustments, and complaints, in accordance with client guidelines, policy contract language, and departmental processes and standards.

Provide education to members and/or member representatives regarding the appeal process, benefits, approvals, denial, etc.

Hewlett Packard, Indianapolis, IN (11/2012 – 11/2015) Third Party Liability Casualty Analyst

Core Expecttions:

Review and research accident and trauma leads and make initial determination to pursue.

Assist IHCP members in understanding the process of resolution for liability cases and the appropriate coordination of available benefits

Maintain constant communication by evaluating facts and evidence, liability, damages and other factors, prior to negotiations with other insurance companies and attorneys in order to maximize subrogation recovery and reach agreement on settlements.

Manage accounts receivables from attorneys and insurers when incidents involve Indiana Health Coverage Program (IHCP) members and third parties who are liable for medical expenses. DEBORAH F. WALKER Phone: 412-***-**** Page 2

UPMC Health Plan, Pittsburgh, PA

Complaints/Grievance Coordinator (06/05-10/12)

(09/99-10/12)

Core Expectations:

Document the results of Member, Provider, Dental and Pharmacy complaints, appeals and disputes at all levels.

Prepared written case summaries for all adverse determination for the purpose of conducting Fair Hearings.

Prepared case file on clinical Member Grievances for the Medical Director for review.

Coordinate and facilitate review hearings and Internal Appeal Committee meetings

Interacted with other departments including Customer Service, Claims, Provider Relations and Pharmacy to resolve member appeals.

Coordination of Benefits Specialist (02/01-06/05)

Core Expectations:

Reviewed insurance applications to determine primary coverage for members. Interface with customers, medical providers and other insurance entities while assisting group enrollment in updating member files to accurately display other insurance coverage.

Tracked results of COB savings to identify overpayments with monthly reports.

Assisted with creating training manuals and course materials of updated COB information.

Coordinated internal and external training programs for Claims Operations. Senior Claims Examiner (09/99-02/01)

Core Expectations:

Process claims in accordance with company policies and procedures in a timely manner.

Resolve outstanding pends in accordance with designated standards.

Maintain employee/insured confidentiality.

Mentor new team members training them on various products and procedures. ACADEMIC ACHIEVEMENTS

CARLOW UNIVERSITY — Pittsburgh, PA

Bachelor of Science (BS) in Business Management, 2010

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