Management Professional eager to contribute significant background in healthcare insurance industry toward supporting a progressive organization in optimizing bottom-line performance.

 

 

• Extensive experience in managed care, especially with medical claims spanning commercial, Medicare, Medigap, dental and pharmacy.
• Considerable strengths in coordinating and overseeing subrogation, fraud investigation, and medical claims appeals.
• Adept at interpreting and analyzing conformance to regulations including Joint Commission, NCQA (National Committee for Quality Assurance ) and CMS (Medicare/Medicaid).
• Exceptional talents in training, coaching, mentoring, supervising and directing high-performing personnel.
• Excel in identifying and implementing process and quality improvements as well as measurable cost-saving initiatives.
• Superior ability to establish cohesive working relationships with all levels of an organization.

• Computer/software skills include proficiency in Microsoft Office.

 

 

UnitedHealth Group/Ingenix, Minneapolis, MN, 2005 to Present

Senior Investigator

• Apply dynamic leadership talents as key member of Referral and Validation Team and Fraud Analytic Team, tasked with analyzing and swiftly resolving critical customer issues.
• Conduct in-depth investigations and present findings to client.
• Co-developed new investigational process to enhance effectiveness and accuracy of facility review.
• Resourcefully examined, created and implemented process improvements for Referral and Validation Team.

 

Network Program Consultant

• Spearheaded development, documentation, analysis, implementation and administration of Hospital Comparison Program designed to share information regarding hospital quality and costs for various medical procedures and conditions.

 

Self-employed, Carver, MN, 2005 to 2007

Consultant

• Merged exemplary client relations, problem solving, and project management expertise to assist customers in rectifying broad-scope issues related to medical claims.

 

Continued

 

 

Professional Experience continued                                                                             Yyyyyy x. yyyyyy C Page 2 of 2

 

CBCA, Bloomington, MN, 2003 to 2004

Appeal and Subrogation Coordinator / Senior Claims Examiner

• Scrutinized appeal documentation to assess and determine alignment with contractual guidelines.
• Exercised polished organizational skills to compile and maintain critical information for subrogation cases.
• Seamlessly communicated with attorney and client regarding case status, settlement options, and course of action.

 

Staff Inc., St. Louis Park, MN / Administrators Overload, Hopkins, MN, 1996 to 2003

Senior Claims Examiner

• Meticulously processed claims for both small companies and large corporations encompassing self-funded and fully-funded plans.
• Successfully completed multiple claim analysis and reconciliation projects on a contract basis.

 

Health Systems Integration, Inc., Bloomington, MN, 1994 to 1996

Billing Eligibility Lead        (1995 to 1996)

• Employed sharp attention to detail to verify client eligibility, coordinate required information for client billing, and ensure strict compliance with government rules and regulations.
• Supervised, mentored, and directed several staff members, consistently emphasizing productivity and accountability.  
• Promoted from role as Senior Claims Examiner (1994 to 1995) based on outstanding performance.

 

Prior background includes roles as Customer Service Representative & Claim Benefit Examiner

for Blue Cross and Blue Shield of Minnesota, Eagan, MN, 1989 to 1994.

 

 

Minnesota State University-Mankato, MN

Bachelor of Science Degree in Business Administration

• Emphasis in Management / Industrial Relations; Minor in Economics

 

 

Training & Seminars Attended:

Claim Benefits (Commercial, Medicare, Medigap, Dental and Pharmacy)           Contract Interpretation

Compliance                                                                                                                                       Customer Service

Correspondence/ Communications                                                                                       Government Programs

Team Building / Conflict Resolution                                                                                      Fraud Investigation

Medical Terminology  

 

 

Member of HIMSS (Healthcare Information and Management Systems Society)