Constance McMillian
Tallahassee,USA
Summary
Experienced Disability Claims Examiner with 3 years of comprehensive experience in assessing and processing Leave of Absence and Disability claims. Expertise in analyzing medical documentation and collaborating effectively with healthcare professionals to ensure compliance with legal standards. Passionate about delivering accurate claim resolutions while managing high workloads efficiently.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Disability Representative
Sedgwick Claims Management Services
11.2024 - Current
- Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to a disability plan.
- Reviews and analyzes complex medical information (i.e. diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.
- Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians).
- Communicates with the claimants providers to set expectations regarding return to work.
- Determines benefits due, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
- Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions.
- Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence.
- Informs claimants of documentation required to process claims, required time frames, payment information and claims status either by phone, written correspondence and/or claims system.
- Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
- Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
- Negotiates return to work with or without job accommodations via the claimants physician and employer.
- Refers cases as appropriate to team lead and clinical case management.
- Maintains professional client relationships.
FMLA Claims Representative
Sedgwick Claims Management Services
06.2022 - Current
- Perform initial set-up and continuously manage claims in the Juris claims management system.
- Investigate, evaluate, and manage call to complete coverage analysis confirming or denying coverage using Xactimate estimating software.
- Prepare necessary state filings within statutory limits, manage litigation and vocational rehabilitation process, used appropriate cost containment techniques.
- Assist the training department in developing CSR training in order to set expectations.
- Create custom templates and guide sheets for new trainees in the CSR Internet division to ensure consistency and increase department efficiency.
- Utilize proper SIU reporting procedures for extensive investigation as required.
- Recognize for developing relationships with SIU and decreasing expenses while insuring appropriate payment.
- Review medical records to complete bodily injury evaluations and complete the negotiation of claims.
- Respond to time sensitive materials, including but not limit to inter-company arbitration hearings and departments of insurance complaints.
- Complete required claim forms for patients to request reimbursement for services render by both developmental pediatrician and psychology staff.
- Analyze claims to determine extent of patients insurance liability, review and negotiate settlements with claimants insurance policy provisions.
- Respond to arbitration hearings (inter-company mediation regarding liability) and file appropriate transcripts and paperwork on behalf of insure.
- Complete field inspection of losses including accurate scope of damages, photographic evidence collection, written estimates utilizing Xactimate estimating software.
- Establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition.
- Generate safety reports and observations with HAZMAT procedures and file all reports daily.
- Reviewed FMLA claims for compliance with federal and state regulations.
- Coordinated communication between employees and management regarding leave requests.
- Managed FMLA claims process for clients with attention to compliance and accuracy.
- Reviewed medical documentation to determine eligibility for leave under FMLA guidelines.
- Coordinated communication between employees, employers, and medical providers regarding claims.
Phlebotomist
Shands Hospital-Gainesville, FL
11.2017 - 06.2022
- Routine Blood Drawing of Inpatient / Outpatient Patients
- Performing Blood Culture
- Neonatal heel sticks
- Knowledgeable in the use of standard phlebotomy equipment such as tourniquets, vaccutainer tubes and sleeves.
- Safely and proper use of butterfly needles and syringes
- Able to allay patient fear and elicit collaboration
- Familiar with medical terminology, first-aid and safety
- Stock Merchandise Knowledge
- Prepare Send out specimens for shipment
- Order Lab Supplies
- Follow infection- control and safety procedures in carrying out daily phlebotomy functions
- Experience Blood Draws on Infant, Adolescents and Geriatric patients
- Blood Specimen Storage
Education
High School -
James A. Shanks High School
Quincy, FLSkills
- Physiology Knowledge
- ICD coding
- Medical Scheduling
- Venipuncture
- Phone Etiquette
- Patient Care
- Medical Records
- Epic
- Working knowledge of anatomy
- Infection control
- Specimen processing
- Medical Office Experience
- ICD-10
- Patient monitoring
- Clerical experience
- Medical billing
- Office Management
- EMR Systems
- HIPAA
- Computer Skills
- Cerner
- Insurance verification
- CPT coding
- Organizational skills
- Computer Operation
- Laboratory Experience
- Medical Terminology
- Filing
- Anatomy Knowledge
- Phlebotomy
- Claims management
- Disability evaluation
- Benefits authorization
- Case coordination
- Report generation
- Effective communication
- Attention to detail
- Time management
- Team collaboration
- Disability assessment
Certification
Certified Phlebotomy Technician
Personal Information
- Willing To Relocate: Anywhere
- Authorized To Work: US for any employer
Timeline
Disability Representative
Sedgwick Claims Management Services
11.2024 - Current
FMLA Claims Representative
Sedgwick Claims Management Services
06.2022 - Current
Phlebotomist
Shands Hospital-Gainesville, FL
11.2017 - 06.2022
High School -
James A. Shanks High School
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