Director, Corporate Claims, Enterprise Services Resume Example
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DIRECTOR, CORPORATE CLAIMS, ENTERPRISE SERVICES
Executive Profile
Energetic and enthusiastic insurance professional motivated to succeed in a fast-pasted and deadline-driven professional environment. Comprehensive knowledge of workers compensation claims operations with concentration in medical bill review, new claims intake, training, quality and compliance.
Skill Highlights
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Core Accomplishments
Medical Bill Review Transition:
- Served as business lead for a medical bill review transition from service bureau to an application service provider (ASP) model resulting in $4m annual enterprise expense savings.
Improved Medical Bill Review Operational performance
- Developed dedicated and specialized staff to support medical bill review performance which includes: medical bill review and compliance advisor, medical bill review trainer and medical bill review quality specialists to support operations which processes excess of 500k bills with north of $5m in charges.
- Enhanced operations to improve use of pathway rule logic, performance oversight via letters of authority and vendor oversight
- Developed trending tool to support performance oversight
Quality and Compliance Program Improvements/Development:
- Continue to mature claims quality program used to evaluate claims outcomes and adherence to enterprise standards and practices.
- Provide dedicated support to communicate regulatory changes as well as execute jurisdictional compliance audits to evaluate adherence to regulatory expectations.
- Support and provide oversight of the brand's plans of actions to drive quality and compliance improvements
Professional Experience
10/2011 - 01/2016
Company Name － City, StateDirector, Corporate Claims, Enterprise Services
- Responsible for corporate claim support and oversight of: Accident Fund, United Heartland, Third Coast Underwriters and CompWest.
- Provide senior leadership for medical bill review, intake, training, quality, compliance and claim support.
- Responsible for collaborative advancements and resolutions in accordance with a Collective Bargaining Agreement.
02/2011 - 10/2011
Company Name － City, StateDirector, Claims Strategy
- Responsible for creating a competitive advantage for United Heartland by the implementation of a client service/management strategy.
- Responsible for implementation of a Risk Management Information System (RMIS) to expand premium opportunities.
- Responsible for building and monitoring of metrics via scorecards/dashboards, workflow improvements and employee councils.
- Provide senior leadership for the training and quality, medical billing, support services and client service specialists.
10/2007 - 02/2011
Company Name － City, StateManager, Claims Operations
- Developed and provided senior leadership of UH's Claims Operations team.
- Identified, developed, documented and implemented workflow and technical improvements to support UH's key results.
- Designed and implemented the Claims Audit Tool allowing for detailed analysis of claims staff performance.
- Manager, Claims Training/Quality - United Heartland, New Berlin WI.
10/2004 - 10/2007
Company Name － City, StateManager, Claims Training and Quality
- Developed training programs for all claim staff as well as an Accelerated Training Program to expedite development of entry level claim professionals.
- Management responsibility for accurate and prompt indemnity payments processing and statutory filings.
- Responsible for claim audit execution to ensure work product and service aligned with expectations and best practices.
01/2003 - 10/2004
Company Name － City, StateWorkers Compensation Senior Claims Representative
- Managed and maintained key account relationships.
- Applied expertise in daily processing of a wide variety of complex claims.
- Managed and processed both worker's compensation and short-term disability claims through the United 24 Program as a Integrated Benefits Representative.
04/2002 - 01/2003
Company Name － City, StateWorkers Compensation Claims Representative III
- Managed and serviced large accounts.
- Exercised authority in claims processing, settlement and resolution.
05/2000 - 04/2002
Company Name － City, StateWorkers Compensation Claims Representative II
- Responsible for account management and individual claim exposures.
- Processed and mitigated claims and exposures as well as litigated claims.
- Workers Compensation I - United Heartland, New Berlin WI.
09/1998 - 05/2000
Company Name － City, StateWorkers Compensation Claims Representative I
- Ensured claim payments adhered to administrative statutes.
- Processed medical and indemnity claims accurately and timely to obtain timely file closure.
07/1996 - 09/1998
Company Name － City, StateWorkers Compensation Claims Technician
- Ensured accurate and timely payment of medical, temporary, permanent and expense benefits as well as associated filings with regulators.
- Assisted Claims Representatives in daily claim handling.
Education
May 1995
University of Wisconsin － City, State, USABachelor of Science: Finance Risk ManagementGPA: GPA: 3.0
Finance Risk Management GPA: 3.0
Skills
medical billing, Quality, strategy, Trainer,
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Resume Overview
School Attended
- University of Wisconsin
Job Titles Held:
- Director, Corporate Claims, Enterprise Services
- Director, Claims Strategy
- Manager, Claims Operations
- Manager, Claims Training and Quality
- Workers Compensation Senior Claims Representative
- Workers Compensation Claims Representative III
- Workers Compensation Claims Representative II
- Workers Compensation Claims Representative I
- Workers Compensation Claims Technician
Degrees
- Bachelor of Science : Finance Risk Management
