CONZUELLO MCMILLAN

SUMMARY

Detail-oriented case worker offering over 15 plus years of claims adjustments with thorough research and informed investigations driven to resolve claims and / or cases fairly while representing the interests of the people and employer. Conducts extensive and well sought out investigations; precisely evaluates losses and can negotiate settlements that satisfy diverse parties. Excellent planning, organizing, and problem solving abilities. Builds and maintains professional and productive relationships and works to understand cases from intake, managing to a closing resolution.

EXPERIENCE

Claims Level II Specialist, 11/2018 - Current

Acaria Health Specialty Pharmacy - Orlando, FL

STD and LTD Representative, 11/2017 - 05/2018

The Hartford - Lake Mary, FL

CONTACT

Address: 7501 Brandywood Circle Apt#201

Winter Park, FL 32792

Phone: 407-***-****

Email: adza0r@r.postjobfree.com

SKILLS

Completed required investigations on referred claims within established timeframes. Meeting constant deadlines daily.

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Identified and collected evidence and determined value to a specific claim to properly assess conditions.

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Reviewed, evaluated and adjusted claims to promote fair and prompt settlement via communication and research.

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• Decreased loss ratios through fair and timely claim processing. Negotiated and settled claims according to information presented through clinicals, research and data verification.

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• Explained premiums owed to policyholders, agents and underwriters. Reviewed data to verify validity of claims and and assists in case management actions.

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• Investigated questionable claims to determine payment authorization.

• Analyzed and audited open claims to calculate additional payments owed. Corresponded with insured or agent to obtain information or inform of account status or changes.

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Served as subject matter expert for non-standard coverage questions, using spreadsheets, databases.

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Modified and updated existing policies and claims to reflect change in beneficiary, amount of coverage or type of insurance.

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• Collaborated with fellow team members to manage large volume of claims. Prepared and reviewed insurance-claim forms and related documents for completeness, specifically for STD and LTD.

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Used insurance rate standards to calculate premiums, refunds, commissions and adjustments, when needed.

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Transcribed data to worksheets and entered data into computer to prepare documents and adjust accounts.

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• Attention to Detail

• Data Collector

• Knowledgeable with hipaa policy forms

Educated with Excellent Verbal and

Written Communication

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Remote Support working from home

experience

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Documentation Development computer

/ database expert utilizing Microsoft:

Excel, Word, Outlook, Windows, etc.

daily.

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Interpersonal Skills interacting with

MDOs, Insurance Carriers, Healthcare

Providers for records and clinical

documentation

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• Defect Analysis and Resolution

Teamwork and collaborator whose fully

aware that the people are the priority.

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Multitasking via prioritizing while

managing high workload daily

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Organizational Skills due to working in

a fast paced environment

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• Collaborative Team Player

• Resolving Problems and Incidents

Held Revenue Specialist, 11/2011 - 05/2017

American HomePatient - Altamonte Springs, FL

EDUCATION AND TRAINING

Bachelor of Arts, English/Pre-Law, 12/2006

Florida Agricultural And Mechanical University - Tallahassee, FL ACCOMPLISHMENTS

Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.

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Collected payments, processed receipts and informed policyholders of outstanding balances.

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Assisted claimants, providers and clients with problems or questions regarding their tax forms or claims.

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Received and submitted payments, updated account information and provided receipts.

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Set up and monitored payment plans through client's accounts receivable balances and processed payments.

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Updated company's database daily with new details regarding collections and activity on delinquent accounts.

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Evaluated pending claims (Zero Billed Report) to identify and resolve problems blocking auto-adjudication.

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• Maintained up-to-date understanding of insurance payment practices.

• Documented file notes clearly and concisely in Therasoft software. Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.

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Inputted data into the system, maintaining accuracy of provider coding information and reported services.

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Sent clinical request and missing information letters to obtain incomplete information.

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• Reviewed claims for accuracy before submitting for billing. Based payment or denials of medical claims upon well-established criteria for claims processing.

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• Accurately processed large volume of medical claims every shift.

• Handled third-party insurance processing tasks to assist patients. Used mailings and phone solicitation and assisted account executives in presentations to groups at company-sponsored gatherings to gain new clientele- MDO.

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Engaged customers and provided high level of service by carefully explaining details about documents.

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• Collaborated with carriers to resolve discrepancies in insurance payments.

• Consistently maintained high customer satisfaction ratings.

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