Claim Examiner/Case Manager Resume

SUMMARY:

Managed criminal history records utilizing computer software
Investigated employee records to ensure the hire of candidates pursuant to the “good moral character” clause
Performed case management in the area of human resources
Knowledge of Criminal Court procedures

PROFESSIONAL EXPERIENCE:

Confidential

Claim Examiner/Case Manager

Responsibilities:

Provide total claim management
Review guidelines for eligibility and obtain and review updated medical evidence for claim decisions.
Compose and send communications to employers and employees within appropriate time frames
Provide support for all assigned accounts working by set time frames to meet quality assurance and client performance guarantees
Strong oral and written communication skills to interact with claimants clearly, concisely, and persuasively.
Knowledge of the Family Medical Leave Act of 1993.
Knowledge of ADA,USERRA and Basic knowledge of medical terminology
Ability to prioritize work continually and produce a significant volume of work efficiently within performance standards.
Ability to work in a face - paced environment with short deadlines.
Ability to demonstrate teamwork by dealing effectively with and mentoring other individuals within the organization.

Confidential

Employment Specialist

Responsibilities:

Receive, and respond to inbound calls from members regarding inquiries about jobs openings and further al goals

Confidential

Member Service Representative

Responsibilities:

Receive, document and respond to all member contacts including member inquiries about Plan benefits, policies and procedures
Investigate and resolve member complaints and concerns in cooperation with Provider Network and other Healthfirst departments.
Provide ongoing and support to in regards to Plan benefits (Medicaid), policies and procedures.

Confidential

Child Protection Investigator

Responsibilities:

Document all referrals/complaints with specificity as to type
Aid local law enforcement officials in fact finding and compiling case information.
Review case files to ascertain the completeness of investigation activities on individual referrals/complaints.

Confidential

Benefits Assistant

Responsibilities:

Verified I-9s, criminal background check, fingerprinting, new hire paperwork and employee health screening
Researched and resolved request for employee inquiries regarding medical, dental, vision, life, disability, & 401k
Conducted new hire orientations and assisted with planning job fairs and employee open enrollment
Able to type 55 WPM, Use multi line telephone
Office duties, Organize patient paper work and insurance forms for scanning
Maintained employee data in PeopleSoft and HR Data Central (HRDC) systems
Screened applicants for initial review, schedules appointments for recruiter/s and sends out daily recruitment letters.
Review guidelines for eligibility and obtain and review updated medical evidence for claim decisions.
Processed and maintained account payable for benefits premiums and state mandated payroll deductions.

Confidential

Intake Counselor

Responsibilities:

Completed Bio-psychosocial assessments and communicate effectively with referral sources and treatment staff
Evaluated individuals referred for services with the purpose of determining the most appropriate treatment

Confidential

Enrollment Specialist

Responsibilities:

Listened to calls through monitoring software, including live calls, recorded calls & side-by-side monitoring and/or reviews enrollment work via reports for proper processing and documentation
Worked in an inbound phone-intensive/call center environment
Assisted claims associates in resolving difficult problems and notified proper payee or beneficiary of the requirements necessary to consider a claim, and reviewed claim requirements upon receipt
Performed necessary follow-up work with physicians and other medical facilities
Advised parties on matters such as general contract provisions, missing or incomplete forms, supporting documents, and status.
Able to type 55 WPM