Claim expert- responsible for correct system setup to ensure accurate payment of claims. Provide system setup direction to UnitedHealth Group to ensure that facility and physician claims are paid according to the member benefits. Resolve medical claim and system set-up issues across multiple claims platforms (UNET/COSMOS). Contributed to the reduction of claim adjustments by performing analysis and reporting results. Participated in COSMOS Release testing.

Establish and maintain effective relationships with internal partners. Deliver fraud, waste and abuse solutions to Ingenix clients. Collaborated with operational teams to ensure state & federal compliance, reimbursement and contract policies are adhered to. Assisted on implementations of recovery and cost containment activities for Ingenix clients. Ensured monthly reports are to client specification and delivered on time.

Established effective relationships with regional and local union representatives and their retiree members to address claim and benefit challenges. Increased customer and provider satisfaction by resolving claim adjudication and customer related issues. Minimized claims rework, by ensuring negotiated benefits were appropriately administrated.Improved business by serving as a dedicated contact to meet the immediate needs of the union representatives and retiree members. Conducted one-to-one educational meetings with members to ensure they have a clear understanding of their benefits.

Crisis intervention manager investigating and resolving complex claim issues and generating operational efficiencies.Led team of three provider service specialists.Managed interface of multiple UHG systems to problem solve and enhance quality to ACN providers and customers. Liaison to three operational sites serving as a subject matter expert for operational systems.Improved operational efficiencies by identifying, designing and submitting system enhancements.Completed monthly reports for senior leadership.

Managed grievances, complaints and appeals within state mandates.Researched and responded to Department of Insurance inquiries working cross-functionally with network and clinical teams to resolve issues within state mandated timeframes. Created database with documentation of responses to avoid rework and ensure no regulatory fines were assessed.

Claims expert responsible for implementing new business, system conversions and migrations. Monitored claim adjudication processes to ensure contractual obligations were met for UBH claims activity that exceeded 2 million claims in 2002.Managed system conversions and new business implementations affecting claims processing for over 6 million covered lives. Represented UBH at all on-site Department of Insurance claims audits. Successfully led meetings between UBH sites and claims payers to solve complex provider, facility and member complaints. Proactively identified systemic issues with contracted providers and facilities, preventing incorrect processing and eliminating rework.