Robert Mckellar Email & Phone Number

Supported fraud and abuse investigations. Gathered electronic documents relating to an appeal request related to a questionable provider. Opened database for Investigators to document investigations and outcomes. Documented investigation outcome in databases for the insurance appeal record. Routed claim determination instructions to health insurance claim adjusters to handle claim payment / denials. Collaborated with insurance areas to resolve any computer edits, medical reviews, insurance eligibility issues and provider payment record issues. Created and proof read provider investigation determination letters to be sent as the appeal response to the provider. Redirected any insurance items that did not pertain to fraud and abuse investigations. Assisted with special projects related to health insurance appeals.

Eden Prairie, Mn

Background checks of physicians and businesses to determine legitimacy of health claim billing to stop health insurance fraud and abuse. Updated data bases of suspect providers and their associates. Trained new employees. Participated in employee selection process. Quality assurance reporting. Special projects when necessary. Assisted with Provider Sanctioning Team. Became Fraud and Abuse Resolution Analyst. Participated in LEAN project to improve efficiency of business processes.

Minnetonka, Mn

Determine medical necessity, pre-authorizations, Department of Insurance complaints, Medicare benefit coordination, and senior bucket appeals, edit appeals, durable medical equipment review, usual and customary review, and attorney responses for self-funded benefit plans.