Experience

Simply Healthcare Plans

• United States
• Insurance
• 200 - 300 Employee

• Claims Trainer

  • May 2014 - Present

  • Interact with Claims Management team to develop goals, measurable performance indicators, and objectives for the Claims Staff. • Maintain the Claims Department policies and procedures current in accordance with CMS and AHCA guidelines. • Identify and report root causes of claims processing EDI/scanned errors to appropriate departments. • A daily willingness to troubleshoot, understand and resolve technical and business issues, duplicate processes. • investigate work processes and identifies areas where procedures and quality could be improved. • Provides departmental workflow support as needed. • Work in collaboration with other department. • Liaison with Sr. Claims Director and Anthem for Reinsurance Reporting. • Maintain the Claims Department training progress reports and review monthly with claims Management team. Show less



Health Care District of Palm Beach County

• United States
• Hospitals and Health Care
• 200 - 300 Employee

• Director of Reimbursement

  • May 2011 - Present

  This position directs operations for the Claims Department, while maintaining performance reimbursement standards and guidelines. Provides oversight and direction to staff and ensures that the day to day operations involved in the medical claims reimbursement process occurs. Maintains knowledge of Medicaid prepaid health contract and other applicable contractual requirements for all lines of business. Reports and validates data to the Senior Management and outside agencies. Establishes department goals and objectives. Create an effective working relationship within and across organizational boundaries. Plan actions to accomplish designated and desired outcomes. Show less



Emblem Health

• Assistant Director

  • Oct 2006 - Oct 2008

  Established and led the COB Financial Recovery Unit 2008 to manage and monitor the trends root cause, recovering an annual savings of $19.5M. Assisgned three senior claims examiners to the Grieves & Appeals Unit, which resulted in maintaining claims complaint deadlines. Created and developed a Claims Trend Report to determine the "Root Causes" for all other claims adjustments for such problems as system issues, examiners training issues, provider relations issues and care management issues. Show less



GoodHealth Worldwide

• Claims Team Leader

  • Mar 2004 - Oct 2005

  Assisted the system support staff in the development of a new claims system and setting priorities. Created reports and negotiated insurance settlements within authorized paramenters. Interviewed claimants, witnesses, and service providers. Assisted the system support staff in the development of a new claims system and setting priorities. Created reports and negotiated insurance settlements within authorized paramenters. Interviewed claimants, witnesses, and service providers.



Risk Based Solutions, RBS RE

• Director of Claims

  • May 1996 - Jul 2003

  Developed automated system and procedures to manage the aggregate monthly reports. Performed on-site aggregated audit on claims over $35,000 and desk audits claims below $35,000. Performed an annual claims audit on any TPA with more than $2M revenue. Maintaining a 10-business day trunaround on claims and pending claims within 90 days. Visited clients annually and attended claims conferences during the year in order to be aware of the latest trends in the reinsurance industry. Developed automated system and procedures to manage the aggregate monthly reports. Performed on-site aggregated audit on claims over $35,000 and desk audits claims below $35,000. Performed an annual claims audit on any TPA with more than $2M revenue. Maintaining a 10-business day trunaround on claims and pending claims within 90 days. Visited clients annually and attended claims conferences during the year in order to be aware of the latest trends in the reinsurance industry.



Symetra

• United States
• Insurance
• 700 & Above Employee

• Supervisor of Reinsurance Claims

  • Mar 1991 - Apr 1996

  Assisted the Legal Department with ligation claims and maintained saving of $1.5M. Designed and developed the claims system with efficient reporting for external and internal users. Recommended a Registered Nurse to monitor the excess claims 50% notices for negotiated arrangements, steering clients to in-network providers for tangible savings. Assisted the Legal Department with ligation claims and maintained saving of $1.5M. Designed and developed the claims system with efficient reporting for external and internal users. Recommended a Registered Nurse to monitor the excess claims 50% notices for negotiated arrangements, steering clients to in-network providers for tangible savings.