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Professional career includes over 39 years of insurance industry experience, which includes claim/customer service operations and cost containment experience, as well as nearly 37 years of managerial/supervisory experience working for carriers, managed care organizations/health plans, third party administrators (“TPAs”), managing general underwriters of medical stop loss insurance (“MGUs”), a reinsurance company, a claim auditing and consulting firm, and cost-containment vendors.
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Vice President, Claims OperationsHealth In Tech Feb 2023 - PresentStuart, Florida, United StatesManage all aspects of the Medical Stop Loss Claims Operations. Includes all business through Health In Tech, International Captive Exchange, Stone Mountain Risk, and Roscommon Insurance Company. -
Vice President Of ClaimsLiberty Mutual Insurance / Ironshore Apr 2021 - Feb 2023Managed the Claims Department responsible for handling Medical Stop Loss, Provider Excess, and HMO Reinsurance claims.
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Founder/CeoIntegrity Claim Solutions, Inc. Aug 2019 - Apr 2021Townsend, DeOwned and operated Integrity Claim Solutions, Inc.Managed all aspects of the Operation, including all Cost Containment and Risk Management Services, such as:- Medical Bill Audits/Reviews and DRG Validations- U&C Reviews and other forms of Claim Re-Pricing (e.g., RBP)- Settlements & Negotiations- Appeal Handling, Claim Auditing Services, and Expert Witness Services- Underwriting Review & Risk Management Services- Review/Assess Plan Documents and Summary Plan Descriptions, Policies, PPO Agreements, etc.- Integrity helped clients save millions of dollars on claims and assisted clients with managing risk.
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Senior Director, Claim Services / ConsultantEthicare Advisors, Inc. / Zelis Healthcare Sep 2011 - Aug 2019Succasunna, NjDuring my time with EthiCare Advisors, Inc. ("EthiCare"), I had overseen all of the day-to-day operational aspects of the organization across all business units, including Claim Settlements/Negotiations, Medical Bill Reviews/Audits, Claim Pricing Services (e.g., U&C/UCR, Medicare-Plus, etc.), Underwriting Review Services, Claim Auditing Services, and general management of the staff. EthiCare Advisors was acquired by Zelis Healthcare in late 2017. I continued my role as a Senior Director for Zelis for quite some time; however, due to changes with my role and shifts in the overall workflow, I chose to step down from my full-time position with Zelis. I started my own company (see additional information in my profile) and I worked with Zelis as a Claim Consultant until February 26, 2020.
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Contractor-Claims AuditorCorporate Benefit Audits Oct 2010 - Sep 2011Worked with Corporate Benefit Audits as a Claims AuditorPerformed a variety a claim auditing services (e.g., aggregate/specific claim audits and TPA operational reviews).
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Insurance Professional - History/Summary. Jan 1984 - Oct 2010> 26 years of insurance operations experience working for carriers, managed care organizations, health plans, third party administrators and a reinsurance company:- Substantial amount of claims and customer service experience;- Experience with provider operations and network relations;- Additional experience with account management, medical utilization management, document management and enrollment & billing functions.> Over 20 years of managerial/supervisory experience:- Managed numerous types of departments and various-sized staff – up to 75 employees.> Knowledge/Experience:- Managed care – HMO, PPO, EPO and POS plans;- Large and small group, individual health and short-term medical business;- Medical stop-loss, excess-loss and reinsurance;- Medicare Advantage and Medicare Private-Fee-For-Service;- Consumer Driven Health Plans;- Accident business and specialty coverage;- Medical terminology and claim coding (e.g.: CPT, ICD-9, HCPCS and UB Revenue Codes);- COB, Subrogation, FMLA, COBRA, HIPAA, ERISA, NCQA and HEDIS.
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Previous Experience - Highlights. Jan 1984 - Oct 2010> Experience with:- Managing claim departments;- Managing claims productivity, quality and inventory;- Maintaining and improving auto-adjudication of claims;- Analyzing claims data and identifying trends/systemic issues;- Auditing claims and performing due diligence audits;- Handling of claim appeals and litigated matters;- Implementing and updating processes, procedures and guidelines;- Managing projects, system implementations and enhancements;- Managing customer service departments/call centers; - Utilizing call center ACD reporting to monitor department performance and to performance manage CSRs; - Managing relationships with business partners (e.g.: stop-loss carriers, reinsurers and brokers/intermediaries);- Managing vendor relationships, as well as negotiation of vendor fees and contractual obligations; - Training employees; - Managing a department budget.
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Additional Highlights. Jan 1984 - Oct 2010> Leadership and relationship-building skills with continued success being achieved during my career by: - Remaining diligent and focused on achieving results;- Effectively managing my time and multiple priorities;- Listening to all of my internal/external customers’ wants/needs and promptly taking action, as needed;- Taking responsibility for department results and taking ownership of issues; - Promptly clearing up service issues and vigorously pursuing global matters before they escalate to more serious concerns;- Appropriately delegating tasks and routinely following up to assure task-completion and issue-resolution; - Constantly striving to improve process work-flow and developing the staff at every level;- Creating a positive work environment for all co-workers and business associates; - Using technology to improve productivity and quality, as well as minimize processing turn-around time.
Frequently Asked Questions about John Nigro
What company does John Nigro work for?
John Nigro works for Health In Tech
What is John Nigro's role at the current company?
John Nigro's current role is Vice President, Claims Operations.
What is John Nigro's email address?
John Nigro's email address is jo****@****ual.com
What is John Nigro's direct phone number?
John Nigro's direct phone number is +163123*****
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John Nigro
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