Manager of a staff of eighteen including customer service representatives, claims processors, case management and support staff. Responsible for training, scheduling, disciplinary action and workflow assignments.
Supervision and oversight of claim processing standards for timeliness and accuracy.
Claim auditing and processing of complex claims.
Review and research of all claim appeals including obtaining records and consultation with Fund attorney and plan consultants when necessary.
Preparation of claim appeals, appeals summaries and reports for Board of Trustees meetings.
Identified and integrated procedures with outside independent peer review companies for claim reviews/appeals.
Streamlined subrogation procedures to maximize member response and repayment resulting in recovery in excess of $250K annually.
Coordinated conversion from insured plan to self-funded plan with PPO network change.
Established in-house case management program resulting in savings in excess of $250K savings per year.
Coordination of plan changes and testing with pharmacy benefit manager including step-therapy program and mail order incentive program.
Primary contact for implementation of system upgrades and testing with medical/dental plan PPO networks.
Coordination with claims system software vendor for programming necessary for benefit plan changes/vendor eligibility reporting and testing of programming changes.
Established procedures for transfer of data to digital imaging through outside vendor and designation of security access to imaging records.
Instrumental in the creation, review and printing of benefit communications including Welfare Fund Summary Plan Descriptions, Summary of Material Modifications and Plan Documents.
Coordinated use of outside vendor for fee negotiation for non-PPO providers resulting in projected savings in excess of $125K annually.
Collaboration with other Fund Office departments regarding employer contributions, benefit and COBRA eligibility.