Hands-on, client-focused Claims Manager with over 7 years of experience managing a robust caseload of long-term disability (LTD) clients. Leverage knowledge of medical terminology and benefit calculations to assure payment of appropriate benefit and offset application, evaluate LTD at each stage of the claim’s life, and accurately interpret and apply policy to each claim. Skilled in assessing and recommending appropriate vocational or medical specialty, and peer review, IME, occupational, or employability assessment. Strong interpersonal and communication skills with ability to interact with clients, employees, medical teams, business partners, and other stakeholders to gather information, offer recommendations, and make decisions.Assess claimants for payment eligibility based on qualification. Consult with clients and medical providers, gathering medical information and ensuring review by appropriate clinical staff. Verifying review and conclusions align with policy requirements. Document claim information clearly, concisely, and accurately. Effectively manage accounts by responding to inquiries, negotiate, arbitrate, and resolve issues, ensuring team meets all performance KPIs.• Achieve overall quality reviews including TL/SCM within standard.• Consistently have higher number of decisions completed (3-4 weekly) by accurately assessing claims based on all available information and making decisions without the need for additional oversight.• Conduct EA, quality and other block reviews to ensure financial and decisional accuracy, identify training opportunities, and provide timely, appropriate feedback to drive continuous improvement. • Train and mentor new hires.

Coordinated and developed comprehensive plans detailing the services and treatments needed to meet client goals in residential, community, and work environments. Facilitated job coaching program with Department of Rehabilitation Service clients to promote and develop work skills and appropriate behavior. Controlled annual budget for individual clients, submitting funding through APS online process and verified service providers aligned with authorized units requested, resolving budgeting issues as needed.• Designed and wrote individualized programming personalized for each client diagnosed with intellectual developmental disabilities.• Ensured program efficiency and evaluated client progress by analyzing monthly data obtained from staff conducting programs and adjusting as needed.• Scheduled, facilitated, and monitored individual program plans, evaluations, and AS assessments.

Title XIX Waiver Service Coordinator: Schedule and facilitate the development of a comprehensive plan that records the service and treatment needed to meet the client’s goals in the residential and community setting throughout the assigned budget year. • Increased caseload from 14 clients to 21. Maintained caseload of 20 Title XIX Waiver participants living in the community residential setting and children living with natural families. • Responsible for scheduling, facilitating and monitoring Individual program plans, evaluations and APS assessments for each client in various settings in the community and in the home.• Assure that all services are utilized as agreed upon by IDT members. Monitor these services in the natural family home, community, Day Habilitation setting and Supported Employment setting. • Coordinated annual budget with team members and outside agencies for each client to submit for funding through the APS online process. Assured that all service providers stay within authorized units requested. Resolved any budgeting issues as they occur and at quarterly intervals.• Maintained communication with all service providers, agencies and guardians involved with client’s treatment to address all issues and concern as they occur. • Facilitated crisis planning as needed for suicidal ideations or maladaptive behavior to secure appropriate treatment and intervention in appropriate setting.