Director, Corporate Claims, Enterprise Services Resume Example Accident Fund Holdings

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

Leadership
Self-motivated
Business operations
Problem-solving

Communication
Collaborative
Customer-oriented
Organization

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

Accident Fund Holdings － Lansing, MIDirector, 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

United Heartland － New Berlin, WIDirector, 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

United Heartland － New Berlin, WIManager, 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

United Heartland － New Berlin, WIManager, 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

United Heartland － New Berlin, WIWorkers 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

United Heartland － New Berlin, WIWorkers Compensation Claims Representative III

Managed and serviced large accounts.
Exercised authority in claims processing, settlement and resolution.

05/2000 - 04/2002

United Heartland － New Berlin, WIWorkers 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

United Heartland － New Berlin, WIWorkers 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

United Heartland － New Berlin, WIWorkers 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 － La Crosse, WI, USABachelor of Science: Finance Risk ManagementGPA: GPA: 3.0

Finance Risk Management GPA: 3.0

Skills

medical billing, Quality, strategy, Trainer,

Resume Overview

Companies Worked For:

Accident Fund Holdings
United Heartland

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

Director, Corporate Claims, Enterprise Services Resume Example

Resume Score: 90%

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