Claims Manager
Resume:
Mary E. Bochnovic
Aurora, Illinois 60506
**********@*****.***
OVERVIEW:
Dedicated and results proven professional with a progressive, ground up career in healthcare and insurance claim auditing, quality control, training, regulatory compliance and supervision. More than 15 years of claims management experience. Comprehensive knowledge of health, dental, disability and FMLA laws and regulations. Excellent ability to determine eligibility for benefits.
Strong track record of success in creating, developing and implementing new strategies, training programs and customer service initiatives to increase efficiencies, quality assurance, staff development and customer satisfaction.
Proficient in all insurance terminology and policies regarding PPO, HMO, POS, Indemnity, MC A & B and Medicaid plans and administration. Efficiently coordinate adjudication efforts. Determine appropriate reserves resulting in cost containment. Utilize appropriate resources to facilitate claim handling and closure.
EXPERIENCE:
PAINTERS DISTRICT COUNCIL #30 (Health & Welfare Fund), Aurora, Illinois
Senior Claims Coordinator, 1999 to 2009
Received, researched, processed and paid/denied medical, Rx, disability, dental and vision claims for a self-funded employee benefit program supporting more than 7,000 members and retirees in three states. Sign off authority of up to $60,000. Partner with director for budgeting, developing reserves, ensuring plan financial stability, plan communication, risk, regulatory compliance, loss prevention, vendor relations, claims auditing, etc. Direct responsibility for evaluating and processing individual health claims. Coordinated claims to ensure implementation of corrective actions. Updated membership eligibility guidelines. Familiar in procedural codes (ICD-9, CPT, HCPCS).
Investigated claims using third parties to ensure accurate payment on policies.
Reviewed medical and policy files while working within HIPAA regulations.
Provided direct claim expertise and issue resolution support to internal and external customers. Managed all facets of researching and auditing claims to ensure compliance and payment/billing accuracy, as well as to clarify discrepancies.
FOX VALLEY MEDICINE, Aurora, Illinois
Claims & Eligibility Manager, 1997 to 1999
Multi-functional manager role with full operational, quality assurance and contract compliance oversight for all claims examination and processing, as well as eligibility for this IPO with more than 30 independent physician offices and 10,000 members. Hired, trained and managed a team of nine claims examiners. Conducted research and plan analysis to determine and verify eligibility for insurance coverage, as well as to execute corrections and updates. Managed and rectified tape errors for electronic eligibility inquiries and provided recommendations for corrective action.
Audited production claims to ensure accuracy of claims calculation and procedures.
Researched and resolved complex claim inquiries and customer appeals.
Utilized expertise in provider concepts, contracts and reimbursement methodologies to identify discrepancies rapidly.
METLIFE, Aurora, Illinois
Claims Examiner, 1985 to 1997
Reviewed and processed a high volume of group medical claims ensuring accurate payments or denials of claims in compliance with contract, federal regulations, codes and policies. Analyzed claims for proper coding and authorized payment as outlined in policy provisions. Coordinated research for rejected payments, including problem identification, changing information and authorizing payment.
EDUCATION:
WAUBONSEE COMMUNITY COLLEGE, Sugar Grove, Illinois
General Studies
COMPUTERS:
Computer literate; proficient in Microsoft Office products, including Word and Excel. Also, proficient in several industry specific applications (ISSI).
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