Experience

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  TFG Partners

  • Pittsburgh, PA

  • Audit Director

    • Aug 1998 - Present
    • Pittsburgh, PA

    Audit DirectorContinue to perform the same job duties as when a claim auditor. Supervise other auditors within the company with their audits. Train as needed and answer the auditor’s questions.Claims AuditorSelected Accomplishments:Perform audits of Insurance Companies and PBM’s to verify that the client’s medical and Prescription Drug benefits are being administered properly. Responsible for the review of the clients SPD’s and verifying how the benefits are to be administered with the client.Provide the programmers with logic to run reports on the clients claims tape data to identify claims that may be paid incorrectly according to the SPD. Also review to determine if there are duplicate claim payments, verify the correct application of coordination of benefits and Medicare. Conduct the onsite audit where samplings of the claims are reviewed to determine if they are paid correctly. Prepare a final report explaining the results of the onsite audit.

• 

  Prudential Health Care

  • Monroeville, PA

  • Senior Claims Advisior

    • Apr 1984 - Dec 1997
    • Monroeville, PA

    Prudential Healthcare, Monroeville, PA 1984-1997 Technical Advisor (1996-1997)Selected Accomplishments:Oversee the Quality Review process, which checks the accuracy of claims processed for group medical plans and provide feedback to other associates. Revalidate internal and external audits, reviewing the results of the audits and implementing any changes that need made as a result of the Audits. Review and process medical claims that were over the authority limits of other associates. Hold meetings to rollout new memos and claim processing procedures to the claim processors throughout the office and provide training as necessary.Claims Approver (1988-1996)Selected Accomplishments:Assist in the Supervision of 15 Claims examiners. Review difficult medical claims in accordance with Company Memos and Plan Provisions. Calculate correct payment of claims processed incorrectly and complete recovery of the overpaid amount.Claim Examiner (1985-1988)Selected Accomplishments:Process medical claims in accordance with the plan provisions of over 50 Group Medical Plans. Answer questions form telephone calls from Clients, Insured and the Provider of services regarding the payment of claims and benefits.Service Assistant (1984-1985)Selected Accomplishments:Open, sort and distribute incoming mail to the appropriate area.