Experience

Total Plan Services/ National General Underwriters

• United States
• Insurance
• 1 - 100 Employee

• Claims Manager

  • Apr 2019 - Present



SPECIAL INSURANCE SERVICES, INC.

• Plano TX

• Claim Adjuster

  • Sep 2018 - Present

  Claim Adjuster - Review and processing GAP coverage. Coordinating benefits with primary and secondary coverage Claim Adjuster - Review and processing GAP coverage. Coordinating benefits with primary and secondary coverage



Exela Technologies

• United States
• Information Technology & Services
• 700 & Above Employee

• Director Of Business Operations

  • Mar 2001 - Aug 2018

  Responsible for four business units, 210+ FTE’s in 4 states, consisting of mailroom and data entry of multiple document types, AP invoices, healthcare claims and medical records processing Management of budget and revenue tracking for all functional areas, strategic planning, operations modeling, metrics development, operational reporting, governance and compliance adherence, policies and procedures, vendor and client relationship management. - Successfully coordinated system and labor force transition during two company acquisitions, with no operational impacts  - Implemented quarterly audit processes and successfully passed all annual SOC and PCI compliance audits - Developed and manage staffing models based on volume trending and operational productivity to meet the changing business mandates.



GTESS, Corporation

• Richardson, TX

• Business Analyst/Implementation Manager

  • Mar 2001 - Jul 2012

  Responsible for new client implementations, client management and overall business process improvements. Create and execute strategic business alignment and spearheaded development initiatives, specifications design of new applications in accordance with client requirements, testing and release of change orders, modifications and enhancements to the processing platform. Improved processing efficiency by studying current practices, resulting in decreased labor expenditures. - Served as subject matter expert and technical testing/acceptance control point for claim validation module to enhance OCR confidence and data pass through rates, resulting in a 40% reduction in keystrokes during data entry exception processing. - Configuration improvement for vendor processing, resulting in a $1 million reduction in vendor costs annually. - Reengineered QC and QC Rollback process to consistently meet all client SLA’s, eliminating penalties. - Provided product and procedure training to business unit and clients, including documentation for ongoing support. - Determined operational objectives by studying business functions; gathering information; evaluating output requirements and formats. - Monitored client service levels by tracking activity; resolving problems, publishing progress reports, and recommending corrective action plans. - Facilitated and documented System to System Integration between the client and BancTec technology platforms, resulting in client acceptance and implementation fee approval. - Developed paper to electronic mapping for client specific EDI file layout creation (ANSI, 837 4010/5010, ECSIF, NSF as well as numerous proprietary formats) - Configured client-based rules and mapping statement for systemically routing electronic claims to PPO partners for repricing, - Configured client-based rules for integration of electronic EDI/Clearinghouse claims acceptance and output.



HEALTHCARE BENEFITS, INC

• United States
• Insurance

• Benefits Analyst

  • Sep 1994 - Feb 2001

  Responsible for driving electronic claims implementation and ongoing claims processing improvements. Identify and train key personnel to move forward with electronic operations, without manual intervention. Assessed process and procedures identified improvement opportunities and implemented improved solutions. - Drove a 50% reduction in labor cost, through automated process implementation - Analyzed and configured plan designs within the RIMS/Trizetto Payment System, - Led critical initiatives to restructure internal business processes with the implementation of electronic Preferred Provider discount calculation and acceptance of EDI Clearinghouse claims.



Travelers Plan Administrators

• United States
• Hospitals and Health Care

• Claims Examiner, Auditor, Supervisor, Manager

  • Feb 1989 - Aug 1994

  1993 - 1994: Responsible for managing claims department unit consisting of the mailroom, customer service, front end data entry, claims adjudication and auditing. - Implemented scorecard and pay per performance compensation model - Reorganized teams to maintain clear segregation of duties reducing costs and improving quality - Oversaw system upgrades and modifications to ensure client quality and turn-a-round SLA’s were met 1991 - 1993: Coordinate and supervised all aspects of the Claims department. Responsible for timely and accurate claims processing, compliance and organizational/client contractual standards. - Supervision of assigned claims staff including performance management, solving employee relations issues, and timely completion of employee evaluations - Provided Claims Examiner training - Assisted with implementations and new product offering evaluations 1989 - 1990: Determines covered medical insurance losses by studying provisions of policy or certificate. Established proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.