Experience

Rafi Law Group

• United States
• Law Practice
• 1 - 100 Employee

• Personal Injury Law

  • Aug 2023 - Present

• Personal Injury Demand Package Reviewer

  • Aug 2023 - Present



American Family Insurance

• United States
• Insurance
• 700 & Above Employee

• Casualty Claims Adjuster II

  • Jan 2017 - Jan 2018

  Investigation and negotiation of automobile accident bodily injury claims with attorneys and claimants. Set reserves as indicated. Medical record review for injuries to ascertain causal relationship to auto accident. Medical bill review using knowledge of ICD-10 and CPT 4 for relationship to injury and usual and customary payment. Negotiation of subrogation and liens. Investigate for possible fraudulent activity and involve Special Investigation Unit when appropriate. Investigation and negotiation of automobile accident bodily injury claims with attorneys and claimants. Set reserves as indicated. Medical record review for injuries to ascertain causal relationship to auto accident. Medical bill review using knowledge of ICD-10 and CPT 4 for relationship to injury and usual and customary payment. Negotiation of subrogation and liens. Investigate for possible fraudulent activity and involve Special Investigation Unit when appropriate.



Oxford Life Insurance Company

• United States
• Insurance
• 1 - 100 Employee

• Sr. Claims/ Appeals and Grievance

  • Jul 2015 - Aug 2016

  Review of Medical Records for payment or denial of life claims. Medical Expert for Appeals Committee. Consult with litigation for proper claim handling. Provide final Medical analysis for Claim Adjudication. Review of Medical Records for payment or denial of life claims. Medical Expert for Appeals Committee. Consult with litigation for proper claim handling. Provide final Medical analysis for Claim Adjudication.



Cognizant

• United States
• IT Services and IT Consulting
• 700 & Above Employee

• Sr Claims Processor/Credentialing Team Lead

  • Jul 2010 - May 2015

  Obtain information regarding health care providers for participation with large national Medicaid insurance plan. Obtain explanations for any match to the National Provider Data Base (NPDB). Updating license renewals for all types of medical providers. Obtain hospital privilege information and review for any disciplinary actions. Ascertain all information on CAQH is accurate and attestations are signed appropriately and up to date. Provide Project Manager with weekly, monthly and yearly reports for credentialing team. Inform team members of changes within the company and legal requirements. Show less



Mercy Care-AHCCCS

• Phoenix, Arizona Area

• Concurrent Review Specialist

  • 2007 - 2010

  On site review of patients medical records to determine continued length of stay per Medicaid (AHCCCS) guidelines. Placement of patients post hospital stay. Consult with physicians and social workers regarding patients plan of care. On site review of patients medical records to determine continued length of stay per Medicaid (AHCCCS) guidelines. Placement of patients post hospital stay. Consult with physicians and social workers regarding patients plan of care.



The Hartford

• United States
• Financial Services
• 700 & Above Employee

• Nurse Consultant-PIP/BI

  • Aug 1996 - Apr 2002

  PIP Adjuster/Medical Consultant Review of medical records for causal relationship of injuries claimed in first (PIP) and third party litigation (auto and homeowner’s claims). Telephonic case management for first party clients, consultant for litigation and PIP team members on personal injury claims. Review of all demand packages prior to Colossus input. Set IME/Peer Review to determine appropriate treatment. Collaboration with SIU department. Review of bills for appropriate CPT-4/ICD-9 coding. Taught CPT-4 and ICD-9 and Medical Terminology classes to claims handlers. Show less



Blue Cross Blue Shield

• Phoenix,AZ

• Medical Review Specialist

  • Aug 1992 - Aug 1996

  Review of appeal and grievance claims for coding, medical necessity, pre-existing, maintenance and other contract exclusions. Process Medicaid/Medicare claims UB40. Representated company on live talk radio show on two occasions. Review of appeal and grievance claims for coding, medical necessity, pre-existing, maintenance and other contract exclusions. Process Medicaid/Medicare claims UB40. Representated company on live talk radio show on two occasions.



Nationwide

• Insurance
• 700 & Above Employee

• PIP/MEDPAY Claim Processor

  • Jul 1990 - May 1992

  Handle all aspects of Personal Injury Protection claims including bill processing and coding, calculation and payment of wages in accordance with individual policy limits. Investigation and collaboration with SIU. Negotiate subrogations and liens. Handle all aspects of Personal Injury Protection claims including bill processing and coding, calculation and payment of wages in accordance with individual policy limits. Investigation and collaboration with SIU. Negotiate subrogations and liens.