Associate STD Claims Administrator Resume Example
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ASSOCIATE STD CLAIMS ADMINISTRATOR
Claims Management and Customer Service
Strong claims expertise and understanding of case management with the ability to adjudicate claims with a solid understanding of policies and procedures. Demonstrate insightful action towards customer service issues and often take extra steps with clients to ensure that superior service has been provided. Excellent interpersonal and analytical skills with ability to accurately make liability determinations. Ability to motivate and manage team members. Strong skills in inter-department relationships and ability to follow protocols to risk manage claims. Self-accountability and proactive solutions to problems with great follow through and insightful thought process.
Skills
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Experience
FMLA Leave & Disability Claims Examiner|Lincoln Financial Group - City , STATE|05/2018 - 09/2019
- Ensures the accuracy and completeness of submitted claims.
- Escalates claims issues/concerns to senior team members and/or management.
- Obtains needed increasingly complex claim information by communicating effectively with internal/external stakeholders, verbally and in written form while maintaining a professional demeanor in all interactions.
- Processes increasingly complex assigned claims for payment or denial in accordance with established procedures and guidelines, in a timely manner and meeting departmental quality/production standards.
- Provides customer service to internal and/or external stakeholders, recognizes what needs to be done to meet customer needs and demonstrates flexibility and responsiveness to meet customer needs on routine work independently.
- Recognizes issues or concerns for assigned area(s) of responsibility, explains effect on the customer's service experience, and suggests process improvements.
- Reviews and provides specific information to increasingly complex questions/concerns from internal/external stakeholders (e.g.
- Internal partners, policyholders, brokers, etc.) by applying expended knowledge.
- Main account Centene Corporation.
STD & Absence Spec I |Liberty Mutual - City , STATE|10/2015 - 05/2018
- Manage caseload of family medical leaves for assigned customers, including review of medical information, to render determinations on family medical leaves in accordance with state and federal laws and regulations.
- Ensure receipt and appropriateness of medical documentation to support leave determination.
- Manage process and required paperwork (electronic and hard copy), using department-specific applications to document activities and manage/complete tasks in accordance with quality and timeliness protocols.
- Respond to inquiries from customers and their employees for Short Term Disability and Absence Management.
- Research and resolve leave-related issues or escalate to next level.
STD Claim Specialist|Metropolitan Life Insurance Company - City , STATE|05/2010 - 07/2015
- Claim owner and decision-maker for Verizon Communications Global account.
- Responsible for administering claims within contractual provisions and internal/external guidelines.
- Establish relationship with claimants in order to understand their perspective on their disability; using that perspective and other information, identifies the claimant's functional capacity and leverages that capacity within the context of the contract to support and encourages return to work as appropriate.
- Keep claimant fully aware of the status of the claim, including setting expectations with the claimant if other resources (Vocational rehabilitation, etc.) will be contacting him/her.
- Assess medical and non-medical barriers for return to work.
- Partner with the claimant, specialty resources, to ensure that each claim has a well-understood plan for the unique situation of each claimant and his/her functional capacity and prognosis.
- Manage overall block of assigned claims, including prioritizing actions, appropriately utilizing resources, and timely and accurate decision.
- Provide a high-level of service to the claimant, including delivering on commitments, 2 hour timely return of phone calls, and clear communication.
- Main account Verizon South.
Associate STD Claims Administrator|SunLife Financial - City , STATE|05/2004 - 05/2010
- Review claim payments within established limits and/or reviews recommendations made by medical resources to determine proper disposition of claims.
- Sets claim action plan to ensure that determinations are adjudicated in a timely, accurate, and efficient manner.
- Interpret contracts and ensures consistent, fair claims practices and adherence to appropriate laws, regulations, and procedures.
- Obtain backup documentation, as necessary, to substantiate claim or to provide service by communicating via telephone with agents, employers (policyholders), claimants, hospitals, physicians, attorneys, and other resources.
- May handle other related duties such as providing technical assistance to other Claims staff or assisting in special projects or assignments as a result of business needs.
Education and Training
Keiser University|CityAssociate of Arts: Health Services Administration
Dean Technical Trade School|City, StateBusiness Certificate
Activities and Honors
Association of Latino Professionals in Finance and Accounting, Member 2008-2010
Languages
Bilingual Spanish/English
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Resume Overview
School Attended
- Keiser University
- Dean Technical Trade School
Job Titles Held:
- FMLA Leave & Disability Claims Examiner
- STD & Absence Spec I
- STD Claim Specialist
- Associate STD Claims Administrator
Degrees
- Associate of Arts : Health Services Administration
Business Certificate
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