Summary
Overview
Work History
Education
Job Title
Timeline
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Janice Morando

Floral Park,New York

Summary

Highly-motivated employee with desire to take on new challenges. Strong work ethic, adaptability, and exceptional interpersonal skills.

Overview

21
21
years of professional experience

Work History

IDR Claims Specialist-Case Management

Ipro
Lake Success, NY
01.2024 - Current
  • Contact both the facility or provider and the health plan to request specific documentation related to the services provided, fees charged, amount of reimbursement for payment amount for an out-of-network service covered by No Surprise rules to make a payment determination
  • Perform payment dispute resolution between providers or facilities and health plans for certain out-of- network services rendered to health plan enrollees.
  • Ensure compliance with federal regulated open negotiation period timelines for IDR requests.
  • Coordinate activities critical to the successful completion of clinical review projects.
  • Analyze requested specific documentation related to services provided, fees and reimbursements.
  • Support programs by monitoring requests, liaising with clinical partners, managing providers and contractor interactions, tracking deliverables and deadlines, and develop project frameworks to support interdisciplinary communications
  • Conduct initial eligibility reviews and recommend a course of action to the internal team.
  • Monitor appeal/dispute status and communication received on client portals
  • Routinely present case/project status using an agile approach to implementation and data presentation

Benefits Analyst

Mutual Of America
New York, NY
09.2021 - 08.2022
  • Authorize and provide support for all pre/post retirement death and disability claim payments for Pension, Thrift, TVI and NAV products.
  • Evaluate forms for validity and determine transaction and trade dates.
  • Establish and calculated post-retirement death claim determinations, and create appropriate correspondence to informants, beneficiaries and beneficiaries' legal representatives, including explanation of benefits and products offered by Mutual of America.
  • Respond to inquiries from regional and home office personnel, employers, and beneficiaries regarding their claims.
  • Correspond with beneficiaries receiving recurring payments; maintain address changes, bank account information, and beneficiary designations; advises dates of last payment; verifies benefits.
  • Analyze and participate in testing of various department functions for system initiatives, enhancements, and regulatory updates.
  • Processed benefit enrollment forms, changes, and terminations.
  • Administered leave programs such as FMLA, PTO, and disability leave, ensuring compliance and proper tracking.

Benefits Authorizer/ Technical Support

Mutual Of America
New York, NY
01.2004 - 09.2021
  • Led and delegated the testing of company products such as 401(a), 403(b), 401(a), IRA, TDA, Defined Contributions and Defined Benefit plans, in order to comply with SEC regulations and product enhancement. In this capacity I have processed and tested Benefit Estimates, Pre-Retirement Estimates, Disability, Withdrawals, Withdrawal Reversals, Terminations, Termination Reversals and Specified Payment Options.
  • Communicated daily with Business Users, Business Analyst, Project Managers in order to create and test numerous functions to ensure that they are working as specified by the Business Requirement Document and the Functional Design Document. These functions include Employer Enrollment, Participant Termination, Withdrawals, Benefit Estimates, Death Benefits, Leave of Absence and Pre-Retirement Estimates.
  • Analyze and identify system related data production problems and assist in the evaluation of system enhancement. Thus, satisfying business priorities including revenue and asset retention goals.
  • Provide feedback and resolution to issues found and ensure all issues are tested thoroughly and closed in a timely manner.
  • Reviewed and processed Participant Termination transactions for takeover plans and corrective contributions for 401(k), 403(b), 401(a) and Defined Contribution Plans.
  • Processed Benefit Claims for Pension and Thrift hardships, such as FLAP, DC, DB, TDA, COL, 401(a) and 401(k) plans in a timely manner.
  • Process Participant Benefit Estimates, reconcile Pension, 401(k) and 403(b) at termination.
  • Assisted with testing special projects as assigned by the manager.
  • Trained new staff on authorization procedures and company policies.
  • Collaborated with development teams to identify and resolve software defects.
  • Analyzed system requirements to create effective testing strategies.
  • Conducted regression testing to ensure software stability after updates.
  • Executed performance tests to evaluate application speed, scalability and reliability under different loads.
  • Assisted in developing acceptance criteria for new projects based on user stories provided by business analysts.
  • Developed test plans, test cases and scripts for various software applications.

Education

B.A - BUSINESS INFORMATION SYSTEMS

DeVry Institute of Technology
New York, NY

Licensed Practical Nurse Certificate -

Veeb School of Practical Nursing
Hicksville, NY

Job Title

Claims Specialist- Case Management

Timeline

IDR Claims Specialist-Case Management

Ipro
01.2024 - Current

Benefits Analyst

Mutual Of America
09.2021 - 08.2022

Benefits Authorizer/ Technical Support

Mutual Of America
01.2004 - 09.2021

B.A - BUSINESS INFORMATION SYSTEMS

DeVry Institute of Technology

Licensed Practical Nurse Certificate -

Veeb School of Practical Nursing

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Janice Morando