Elizabeth D. Email & Phone Number

Massachusetts, United States

Review and process Stop Loss Medical Claims, specializing in the ASO/BUCA claim administrators. Streamlined the ASO/BUCA processes, creating a workflow of claims maintaining the target turnaround time and improving customer satisfactionTechnical resource for claim system enhancements. Updating and adding to the system user manual. Trained end user on new system functionality. Complete quarterly SOX audits: Ensured compliance with the departments policies and procedures, internal controls, and audits results, for both Stop Loss and Specialty Accident. Train incoming auditors on systems and department procedures.Responsible for monitoring individual team members’ performance; maintaining metric data and trending information for training opportunities within the team.Review and Process Specialty Accident claim referrals.

Greater Boston Area

Review and process Stop Loss Medical Claims, specializing in the ASO/BUCA claim administrators. Streamlined the ASO/BUCA processes, creating a workflow of claims maintaining the target turnaround time and improving customer satisfactionTechnical resource for claim system enhancements. Updating and adding to the system user manual. Trained end user on new system functionality. Complete quarterly SOX audits: Ensured compliance with the departments policies and procedures, internal controls,and audits results,Train incoming auditors on systems and department procedures.Responsible for monitoring individual team members’ performance; maintaining metric data and trending information for training opportunities within the team.

Greater Boston Area

Review and process Stop Loss Medical Claims, specializing in the ASO/BUCA claim administrators. Streamlined the ASO/BUCA processes, creating a workflow of claims maintaining the target turnaround time and improving customer satisfactionTechnical resource for claim system enhancements. Updating and adding to the system user manual. Trained end user on new system functionality. Complete quarterly SOX audits: Ensured compliance with the departments policies and procedures, internal controls,and audits results,

Managed claims department of 18+ staff, providing an oversight of the department activities to meet the products' financial and service goals. Managed claim payments totaling $380 million for 1700 policies. Maintained high quality service standards within the staff, provided technical guidance and supported the staff with complex claims issuesForecast future department staffing needs, by creating measurements/metrics for reporting inventory, staff productivity and capacity modelsCreated and enhanced workflow and technical assistance for specialized blocks of business with respect to external working relationships including policyholders, third party administrators, brokers, as well as internal functional areas, underwriting, actuarial/finance, product development and TPA relations. Collaborated with Quality Assurance to determine training needs for examiners, implementing 1x1 training for examiners and reduced overpayments by 75%. Ensured compliance with the departments policies and procedures, internal controls, audit, business continuity, OSFI and Sarbanes-Oxley guidelines Participated in depositions, and mediations by having an in depth knowledge of the Stop Loss contract, third party contract language, and processes and procedures resulting in zero risk.Identified gaps in contract leading to Stop Loss Contract re-write.Lead Claims Employee Benefit Team during acquisition of Genworth Financial to determine best practices between both claims departments.

Claims Manager, Stop Loss Claims (2003-2006) Hired, trained, performance management, bench strength development, and evaluations of personnel resulting in several promotions of staff and low attritions.Implemented tracking process for incoming claims, to eliminate errors and ensure accurate dollars were being reported. Streamlined processes, creating a successful workflow of claims maintaining the target turnaround time and improving customer satisfaction. Reviewed and determined data to define the departmental and system needs ensuring that controls were in place and procedures were current and in compliance with various Corporate, State, and Federal regulations.Initiated and created reports for claims department goals and supporting areas to maintain turnaround time, claims production and estimated liabilities. Maintained departmental policies and procedures due to industry trends.Reviewed complex cases, responded to Insurance Commissioner Complaints, and resolved legal issues by settling or initiating further actions within approved authority limits. Created a team of claims examiners and case managers to review high dollar denials to validate claims decision.

Processed Stop Loss Medical Claims Technical expert and Key resource for claim system enhancements. Creating the system user manual. Trained end user on new system functionality within project timeline, scope and budget. Co-Created Policy and Procedures for Stop Loss claims processes.Collaborated with other areas of stop loss for re-engineering stop loss product, which included improving and enhancing the stop loss contract, claim form and claim requirements.