Carl Anderson
Special Investigations Unit - Manager at Security Health Plan- Claim this Profile
Click to upgrade to our gold package
for the full feature experience.
Topline Score
Bio
Credentials
-
Certified Professional Coder
AAPC -
License – Accident, Health, and Life Insurance
Wisconsin Office of the Commissioner of Insurance (OCI)
Experience
-
Security Health Plan
-
Insurance
-
200 - 300 Employee
-
Special Investigations Unit - Manager
-
2014 - Present
Promoted to Manager to lead the SIU, charged with finding FWA following Medicare CMS, Medicaid ForwardHealth, and general coding guidelines. Report to the Chief Legal and Compliance Officer. ✦ Lead, coach, and guide staff of six (three CPC Certified Special Investigators and three Registered Nurses) through the strategy, investigation, and next steps to ensure accuracy throughout the process. ✦ Implemented FWA strategic plan, which improves the focus on billing specifics and clarifies the targets. ✦ Conduct analysis using Cotiviti STARSSentinel FWA software as well as BusinessObjects reporting software. ✦ Point of contact and follow up on allegations for FWA referrals sent by members, providers, and SHP employees. ✦ Achieved a high Leader Index score of 92 via the Press Ganey assessment based on employee engagement survey. ✦ As SHP Rep. of Wisconsin Medical Group Management Association, respond to coding and benefits questions. ✦ Selected as member of Health Services Policies and Procedures Committee to help streamline policies. ✦ Represented SHP at Wisconsin Department of Health Services (DHS), Office of Inspector General (OIG), Medicaid Fraud Control & Elder Abuse Unit (MFCEAU), Health Maintenance Organization (HMO), and Bureau of Benefits Management (BBM), providing input to the committee. ✦ Transitioned to the carrier side of insurance as the Assistant Manager for the SIU. Show less
-
-
-
Benefits Concepts
-
Weston, Wisconsin, United States
-
Account Manager
-
2011 - 2014
Managed health insurance and ancillary benefits packages for Wisconsin commercial and individual accounts. ✦ Strategized and discussed the overall picture with clients to determine how to create the best benefits products mix to attract the highest caliber of employees. ✦ Assured account retention and met small business owner needs, independently servicing multiple renewals. ✦ Conducted annual benefit reviews for clients and prospects to strategize and determine the best and most cost-effective proposal for each client in value and benefits. Show less
-
-
-
Compass Insurance Services a Division of HUB International
-
United States
-
Insurance
-
1 - 100 Employee
-
Account Manager
-
2008 - 2011
Recruited to manage health insurance and ancillary benefits packages for River Valley Insurance, which later changed its name to IB Insurance and was acquired by Compass Insurance. My primary focus was on commercial accounts. ✦ Built a small block of business initially and expanded to a larger account base. ✦ Serviced multiple renewals for small groups to ensure account retention and meet small business owner needs. ✦ Transitioned from an independent agency to a wholly owned subsidiary of a major bank with no prior health insurance operations. Assisted with creating a cohesive transition for the new division. ✦ Interfaced with clients to resolve billing, eligibility, or claims issues, creating rapid resolutions. ✦ Educated clients on benefit options to help them select the best plan for their particular needs. Show less
-
-
-
WPS Health Insurance
-
United States
-
Insurance
-
700 & Above Employee
-
Sales Associate
-
2006 - 2008
Transitioned to build successful relationships as a liaison with agents for health insurance policies and ancillary products. ✦ Managed information gathering, submission, and follow-through process for group change requests.✦ Trained agents in WPS processes and procedures while promoting the use of the WPS website for agents and their clients.
-
-
Customer Service Consultant
-
2004 - 2006
Managed large group business for WPS for 51+ insurance and self-funded clients from pre-sale to successful renewal.✦ Directed account retention, assisting in ongoing evaluation and design of corporate customers’ benefit plans.✦ Designed group reporting package utilizing and analyzing Data Dashboard information.✦ Conducted onsite visits enabling employees to personally discuss claims or benefits issues. Improved client relations with employees who expressed concerns about their benefit plans.✦ Trained and educated staff members on challenging services, such as Medco and benefits questions.✦ Liaisoned between the customer and Subject Matter Expert to resolve issues. Show less
-
-
-
UnitedHealth Group
-
Hospitals and Health Care
-
700 & Above Employee
-
Unit Supervisor
-
1999 - 2002
As Unit Supervisor for Wausau Benefits, increased team productivity by 12% per Customer Service Representative by working with staff members to build self-motivation and improved work procedures.✦ Oversaw health claims processing according to respective plan provisions, resulting in 99% payment accuracy, 97% procedural accuracy and 99% financial accuracy.
-
-
Claim Service Representative
-
1997 - 1999
As Claim Service Representative for Wausau Insurance, worked closely with customers to answer inquiries and resolve issues. Determined amounts payable on health claims.✦ Promoted to Unit Supervisor because of strong proficiencies and skills as a Claims Service Representative, with the ability to lead other CSRs and help them achieve success.
-
-
Education
-
University of Wisconsin-Parkside
Bachelor of Science - BS, Finance, General
Community
